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Suspected Cigarette Caused Fire Report Form

suspected cigarette caused fire form header
This form is to be filled by the lead investigator conducting the investigation within 24 hours of the incident
Incident Information
Incident Date*   Incident Time*     (00:00 am/pm or 24hr.)
FDID #*   FD Incident #*  
Fire Department*  
Fire Department Contact Information
Incident Commander*  
Title*  
Day Phone*   Evening Phone   Cell Phone  
Investigator Information
Investigator*  
Agency*  
Day Phone*   Evening Phone   Cell Phone  
Incident Location
Address*  
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