Minnesota State Fire Marshal
Suspected Cigarette Caused Fire Report Form

This form is to be filled out by the lead investigator conducting the investigation within 24 hours of the incident.

Fields marked with * are required.

Incident Information
Incident Date*   Incident Time*     (00:00 am/pm or 24hr.)
FDID #*   FD Incident #*  
Fire Department*  
Fire Department Contact Information
Incident Commander*  
Day Phone*   Evening Phone   Cell Phone  
Investigator Information
Day Phone*   Evening Phone   Cell Phone  
Incident Location
City*   ZIP*   County*  
Fire Information
Type of Fire*   Other 
Area / Room of Fire Origin*
Material First Ignited*
Number of Injuries:   Adult*   Child*   Firefighter*  
Number of Deaths:   Adult*   Child*   Firefighter*  
Estimated Dollar Loss:   None
Cigarette Information
Suspect Cigarette Package Marked Fire Standard Compliant (FSC)*
MN Tax Stamp on Package*
Package Available for Inspection*
Photographs Available for Review:  If yes: 
Brand   Packaging* 
Brand Style (Filter, Menthol, King, Length, etc.)  
Additional Comments