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Incident Report
National Association of Fire Equipment Distributors
Portable/Wheeled Fire Extinguisher Incident Report




Distributor
Location
Date of Report
Date of Incident
Indicate quantity and type of extinguisher(s) used.
Capacity ABC Dry Chem BC Dry Chem CO2 Purple K Class D Clean Agent
2-5 lbs.
6-10 lbs.
11-15 lbs.
16-20 lbs.
21-30 lbs.
>30 lbs.
Capacity Press. Water K Class Water Mist Loaded Stream AFFF FFFP
1.5 gal.
1.8 gal.
2.5 gal.
6 liter
33 gal
Classification(s) of Fire: Class A Class B Class C Class D Class K
Types of Occupancy:
Assembly Residential Industrial
Education Lodging Storage
Day Care Residential Board & Care Vehicle
Health Care Mercantile Other
Detention/Correction Business
Did extinguisher(s) extinguish fire? YES NO
If NO, how was fire extinguished?
Sprinkler System Fire Department Self-Extinguished
Other Suppression System Occupant Use Hose Other
If extinguisher failed to extinguish fire, why?
Fire Too Large Extinguisher Not Full Extinguisher Malfunction (see below)
Operator Error Extinguisher Not Pressurized Unkown
Operator Not Trained Wrong Type of Extinguisher Other
Reason for malfunction:
No Maintenance Valve Failed to Open Other
Improper Recharge Unknown
Was Fire Department Called? YES NO If YES, was Fire Department needed? YES NO
Was fire area sprinklered? YES NO If YES, did sprinklers operate? YES NO
Additional Information:






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