Form FEMA Form 078-0-1 FEMA Form 078-0-1 Request for Fire Management Assistance Declaration

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

O.M.B. No. 1660-0058
Expires August 31, 2011

REQUEST FOR FIRE MANAGEMENT ASSISTANCE DECLARATION

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 1 hour per response. The burden estimate includes the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. This collection of information is required to
obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send
comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of
Homeland Security, Federal Emergency Management Agency, 1800 South Bell Street, Arlington, VA 20598-3005, Paperwork Reduction Project (1660-0058) NOTE: Do
not send your completed form to this address.
1. STATE

2. DATE OF REQUEST

3. TIME OF REQUEST

4. NAME OF GOVERNOR OR AUTHORIZED REPRESENTATIVE

PHONE NO. INCLUDING AREA CODE
a. Day
ADDRESS (Street, City, Zip)

5. AGENCY REPRESENTED

b. Night

NOTE: In making this request, the Government agrees to abide by provisions contained in FEMA-State Agreement for Fire Management Assistance under Section 420,
PI 93-288 as amended. This request must be signed below by the Governor personally or by his authorized representative, whom he has previously authorized to sign
this request in the FEMA - State Agreement.
6. SIGNATURE

TITLE

DATE

I. EXISTING CONDITIONS
a. TEMPERATURE
b. RELATIVE HUMIDITY c. DIRECTION AND VELOCITY OF WIND
7.
EXISTENCE OF
HIGH
d. PREVAILING WEATHER CONDITIONS AND PREDICTIONS FOR NEXT 24 HOURS
FIRE DANGER
CONDITIONS
8. NUMBER OF WILD FIRES
a. CONTROLLED

ACRES BURNED

b. UNCONTROLLED

ACRES BURNED

c. EXISTENCE OF OTHER FIRES NEARBY WHICH LIMITS THE COMMITMENT OF STATE FIRE FIGHTING RESOURCES #
d. EXISTENCE OF OTHER FIRES NEARBY THAT MAY RESULT IN A CONFLAGRATION #
9. INDICES:

10. STATE & LOCAL
NATIONAL FIRE DANGER RATING SYSTEM
OTHER (KBDI, SPI, HAINES, PALMER, ETC.)

BURN BANS:

YES

NO

YES

NO

11. NATIONAL
WATCHES:

WARNINGS

YES

NO

II. FIRE SITUATION REPORT
12. TIME OF REPORT

13. NAME OF UNCONTROLLED FIRE

15. LOCATION OF UNCONTROLLED FIRE: (County)

14. DATE
16. ACRES BURNING:
a. FEDERAL

%

b. STATE

17. MANPOWER AND RESOURCES COMMITTED (Attach separate sheet if necessary)
STATE:

LOCAL:

18. TYPE AND AMOUNT OF FEDERAL OR OTHER ASSETS & RESOURCES NEEDED: (FEMA does not order resources)

FEMA Form 078-0-1, MM/YY

PREVIOUSLY FF 90-58

%

c. PRIVATE

%

III. CURRENT THREAT
19. THREAT TO LIFE:

a. PREPARATIONS MADE FOR EVACUATION?
YES

#

b. PERSONS EVACUATED:

NO

#

ADDITIONAL INFORMATION

20. NAME AND LOCATION OF COMMUNITY THREATENED
TOWN

CITY
SUBDIVISION

21. CASUALTIES:

22. THREAT TO PRIVATE PROPERTY: (Dwellings)

1. CIVILIAN LOSS OF LIFE

1. NUMBER OF HOMES

2. CIVILIANS INJURED
3. FIRE FIGHTERS LOSS OF LIFE

a. % OF PRIMARY

b. % OF SECONDARY

4. FIRE FIGHTERS INJURED
23. THREAT TO FACILITIES (Include number when applicable)

TYPE

AMOUNT

AMOUNT

BUILDINGS

RECREATION

ROADS & BRIDGES

EQUIPMENT

INFASTRUCTURE

BUSINESS

UTILITIES

OTHER

ADDITIONAL INFORMATION

24. THREAT TO RESOURCES
WATERSHED

WILDLIFE (Type threatened, fur-bearing animals, big game, etc.)

IRRIGATION

ENVIRONMENTAL RESOURCES (bio-diverse areas, etc.)

FLOOD CONTROL

CULTURAL RESOURCES

FISHING STREAMS & SPAWNING SITES

ECONOMIC INJURY

ADDITIONAL INFORMATION

IV. STATE ASSESSMENT
25. EMERGENCY MANAGEMENT ASSESSMENT OF THE SITUATION

SIGNATURE

DATE

26. FORESTRY ASSESSMENT OF THE SITUATION
SIGNATURE

DATE

FOR FEMA REGIONAL USE ONLY
SIGNATURE

FEMA Form 078-0-1, MM/YY

TITLE

DATE

PREVIOUSLY FF 90-58

TYPE