Basic Incident Information

Case Number

(provided by JFSIP)

Fire Department

Interventionist First Name

Interventionist Last Name

Contact Number

Alarm Number

(if applicable)

Reported to NFIRS

Was the incident reported as a juvenile set fire in NFIRS?

Incident Address

Street

City

County

Illinois Counties

ZIP/Postal Code

Juvenile First Name

Juvenile Last Name

Parent/Guardian First Name

Parent/Guardian Last Name

Juvenile Age

Juvenile Grade Level

Gender

Update of a Previous Post

Check if true.

Known Previous Fires Set

Number of Injuries

Number of People Displaced

Dollar Loss Estimate

(per Report)

Referral Source

Family Unit

Caregiver at the time of the incident

Age of Sitter

(if selected)

Incident Involvement

Incident Location

Ignition Method

Accelerant

Was an accelerant used? Check if true.

Source of Ignition Method

Material Ignited

Referral Juvenile Justice

If "Referral to juvenile justice" was selected; enter details here.

Brief Description of the Incident

Description of Eduction

Description of Intervention/Fire Safety Education Provided.