Survey for Allocation of Resources for Fire Serv and Eme

Draft Survey Instrument for “Allocation of Resources for Fire Service and Emergency Medical Service” Project
February 2007

Login Page: Login Identification Number:

Password:

Acknowledgment Page: Welcome to the Community Risk Project Data Entry Portal.

OMB Control No: 0693-xxxx Expiration Date: mm/dd/year.

The “Allocation of Resources for Fire Service and Emergency Medical Service” Project information collection is authorized by the U.S. Office of Management and Budget. Your response is voluntary. Public reporting for this collection of information is estimated to average 5 minutes per response, including the time of reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of information. Send comments regarding this estimate or any other aspects of this collection of information, including suggestions for reducing the length of this questionnaire, to the National Institute of Standards and Technology, 100 Bureau Drive, Stop 1710, Gaithersburg, MD 20899-1710 and the U.S. Office of Management and Budget, Office of Information and Regulatory Affairs, Washington, D.C. 20503.

Accurately completing this survey will contribute to better understanding of community hazards and mitigation strategies, along with improved allocation of fire service and emergency medical resources. Thank you for your time and effort.

Press the button to enter data for the first incident.

Property Page:

Please describe the property you responded to:

Occupancy Type: (Business, Residential, Board and Care, Other, Unknown, N/A)

Square Footage: (0 – 999,999 sf, Unknown, N/A)

Number of Stories: (0 – 999 stories, Unknown, N/A)

Sides of Access: (0 – 4, Unknown, N/A)

Fuel Characteristics: (Slow, Medium, Fast Fire Growth Rate, Explosion, Unknown, N/A)

Alarm: (Present, Not Present, Unknown, N/A)

Building Value: (0 – 999,999,999,999 dollars, Unknown, N/A)

Compartmentation (Compartmented with 2 or more hour fire ratings, Compartmented without fire rating, Uncompartmented, Unknown, N/A)

Age (0 – 999 years, Unknown, N/A)

Built-in Fire Protection Systems (Present, Not Present, Unknown, N/A)

Press the button to save data and continue to the population characteristics.

Population Page:

Please describe the nature of the occupant(s) involved in the incident:

Number of Civilians Present (0 – 999,999 persons, Unknown, N/A)

Reported (Census) Education of Civilians (High School or Less, College Educated, Mix of all Education Levels, Unknown, N/A)

Reported (Census) Median Annual Income of Civilians (less than $25,000, $25,000 – $50,000, $50,000 to $75,000, greater than $75,000, Unknown, N/A)

Press the button to save data and continue to the community assets page.

Community Assets Page:

Please describe the incident involved property of significant importance to the community, including:

Building or Instrument of Governance, such as city hall, courts, fire or police station (Yes, No, Unknown, N/A)

Building, Monument, or Property of cultural significance (Yes, No, Unknown, N/A)

Building, Business, or Property of substantial economic significance (Yes, No Unknown, N/A)

Public Infrastructure, such as roads, bridges, tunnels, water supply, etc. (Yes, No, Unknown, N/A)

Building or Property which is part of the community health infrastructure, such as a hospital (Yes, No, Unknown, N/A)

Press the button to save data and continue to the response page.

Response Page

Please describe the characteristics of your transit to the incident:

Distance (0 – 99 miles, Unknown, N/A)

Traffic (Light, Moderate, Heavy, Unknown, N/A)

Natural Barriers, such as rivers, mountains, bodies of water (Yes, No Unknown, N/A)

Precipitation (Yes, No, Unknown, N/A)

Temperature (-50 to 120 degrees F, Unknown, N/A)

Time of Day (0:00 to 23:59, Unknown, N/A)

Traffic Control Devices (0 – 99, Unknown, N/A)

Press the button to save data and continue to the special hazards page.

Special Hazards Page

Please describe whether this incident involved any of the following special hazards:

Highway or Major Roadway (Yes, No, Unknown, N/A)

Rail Line (Yes, No, Unknown, N/A)

Body of Water (Yes, No, Unknown, N/A)

Hazardous Materials (Yes, No, Unknown, N/A)

Press the button to save data and continue to prevention activities page.

Prevention Activities (Would only have to be entered once per respondent)

Please describe whether your department conducts any of the following prevention activities:

Building Inspections and Building Code Enforcement (Yes, No, Unknown, N/A)

Public Education Activities (Yes, No, Unknown, N/A)

Community Distribution of Smoke Detectors (Yes, No, Unknown, N/A)

Community Distribution of Flu Shots (Yes, No, Unknown, N/A)

Command/Control System (Yes, No, Unknown, N/A)

Emergency Responder Fitness Program (Yes, No, Unknown, N/A)

Press the button to save data and continue to the pre-planning page.

Pre-Planning Page (Would only have to be entered once per respondent)

Please describe whether your department conducts any of the following pre-planning activities:

Pre-incident property planning (Yes, No, Unknown, N/A)

Dispatch (Yes, No, Unknown, N/A)

AVL-GPS (Yes, No, Unknown, N/A)

Risk Management Program (Yes, No, Unknown, N/A)

Press the button to save data and continue to the emergency responders page.

Emergency Responders Page (filled out once for each piece of equipment/apparatus deployed for every incident):

Number of people on apparatus (1 – 9 persons, Unknown, N/A)

Certifications (Yes, No, Unknown, N/A)

Training (0 – 999 hours per person per year, Unknown, N/A)

Experience (0 – 999 total years per apparatus, Unknown, N/A)

Run Frequency (0 – 99 calls per day, Unknown, N/A)

Press the button to save data and continue to the apparatus and equipment page.

Apparatus and Equipment Page

Please list the apparatus and equipment deployed to this incident:

Vehicles: Truck (0 – 99, Unknown, N/A)

Engine (0 – 99, Unknown, N/A)

Ambulance (0 – 99, Unknown, N/A)

Special Hazard (0 – 99, Unknown, N/A)

Communications (Categories, Unknown, N/A)

Supplies (Categories, Unknown, N/A)

Personal Prot. Equipment (Categories, Unknown, N/A)

Maintenance (Categories, Unknown, N/A)

Press the button to save data and continue to the intervention page.

Intervention Page

Please identify the length of time from when the emergency call was received until intervention activity was initiated:

Fire: (1-999 minutes, Unknown, N/A)

EMS: (1-999 minutes, Unknown, N/A)

HazMat: (1-999 minutes, Unknown, N/A)

Technical Rescue: (1-999 minutes, Unknown, N/A)

Press the button to save data and continue to the community risk page.

Community Risk Page

Please indicate economic losses, as well as any injuries or deaths observed as a result of incident:

Total Losses: Direct: ($0 - $999,999,999,999.99, Unknown, N/A)

Indirect: ($0 - $999,999,999,999.99, Unknown, N/A)

Emergency Responders:

Injuries: (0 – 999, Unknown, N/A)

Deaths: (0 – 999, Unknown, N/A)

Civilians: Injuries (0 – 999, Unknown, N/A)

Deaths (0 – 999, Unknown, N/A)

Press the button to save data and complete the data entry for this incident.

Thank you for participating in this important project.

4