Nfirs Module 6 Ems

NFIRS 5.
0 Self-Study Program
Emergency Medical
Services (EMS) Module:
NFIRS-6
Objectives
After completing the EMS Module the student will be able to:
1. Identify the different modules that are used to record casualties.
2. Understand the need for the various modules and which module to
use in various circumstances.
3. Demonstrate how to complete the EMS Module, given hypothetical
narrative reports.
6-1
Table of Contents
Pretest #6 - Emergency Medical Services (EMS) Module. . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-3
Using the EMS Module. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-4
Section A: FDID, State, Incident Number, Incident. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-5
Section B: Number of Patients and Patient Number. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-5
Section C: Date/Time. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-5
Section D: Provider Impression/Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-6
Section E: Age or Date of Birth, Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-6
Section F: Race, Ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-7
Section G: Human Factors Contributing to Injury and Other Factors. . . . . . . . . . . . . . . . . . . 6-7
Section H: Body Site of Injury, Injury Type, and Cause of Injury/Illness. . . . . . . . . . . . . . . . . 6-8
Section I: Procedures Used. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-9
Section J: Safety Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-9
Section K: Cardiac Arrest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-10
Section L: Initial Level of Provider and Highest Level of Care Provided on Scene. . . . . . . . . 6-10
Section M: Patient Status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-11
Section N: Disposition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-11
SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-12
EXAMPLE: Injured Person. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-13
EXERCISE SCENARIO 6.1: Unconscious Person. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-15
EXERCISE SCENARIO 6-2: MVA on I-95. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-18
NFIRS 5.0 Self-Study Program
Pretest #6 - Emergency Medical Services (EMS) Module

1. A Basic Module must be completed if the EMS Module is completed.
(a) True.
(b) False.
2. EMS-type activities are a significant portion of a fire department’s operational workload.

(a) True.
(b) False.
3. The EMS Module is a required NFIRS Module.

(a) True.
(b) False.
4. The purpose of the EMS Module is to gather basic data as they relate to the provision of emer-
gency medical care by local fire service units.
(a) True.
(b) False.
5. The EMS Module can be used instead of the Fire Service Casualty Module to document a fire-
fighter injury.
(a) True.
(b) False.
6-3
Using the EMS Module
I n its infancy, fire department activity reporting was limited to fires only - at least on a national
level. Little recognition was given to the “other” activities that fire departments were perform-
ing on a daily basis. As fire department management became more responsive to the budgetary
concerns and restrictions of fiscal policy, the need to justify all activities and expenditures grew.
Many local fire departments began to collect data on their own, using the NFIRS program to
attempt to gather management information concerning all of those other activities and stretching
the program in directions that were never anticipated. Recognizing that EMS-type activities are a
significant portion (well over 50 percent) of a fire department’s operational workload, the EMS
Module was created in 1996.
The EMS Module is an optional module. It should be used when that option has been chosen by
your State or local authorities. The EMS Module is not intended to replace or otherwise interfere with
State or local EMS patient care reporting requirements, nor is it intended to be a comprehensive EMS
patient care report. Instead, the data elements in this module should be viewed as “core elements”
around which a complete patient care report can be built.
The purpose of the EMS Module is to gather basic data as they relate to the provision of emergency
medical care by local fire service units. It is intended to encompass both responding fire suppression
units and fire department EMS units.
Use the optional EMS Module to report each medical incident that a department responds to. This
module is completed only if the fire department provides emergency medical service. If an indepen-
dent provider performs EMS, do not use this module.
NOTE: Data on fire services injuries or deaths are recorded on the Fire Service Casualty Module.The EMS Module does not replace
the Civilian Fire Casualty Module in cases where a civilian injury or death results from a fire incident.
Whenever specific 300 series Incident Types (e.g., 311, 322, 371, etc.) are entered on the Basic
Module, Section C, you also may complete the EMS Module. It also may be completed for injuries
treated in certain other incident types (consult the CRG for specifics).
One EMS Module should be completed for each patient, and the number of modules submitted for
an incident should match the Number of Patients entered in Block B of the paper form.
Section A: FDID, State, Incident Number, Incident

MM DD YYYY NFIRS–6
Delete
A Change EMS
FDID State Incident Date Station Incident Number Exposure
Month Day Year Hour/Min

Number of Patients Patient Number Date/Time
B information in Section A of the EMS
The C Module is drawn from
Time Arrived Section A of the Basic Module. Use
at Patient
Check if same date
the
Usedata inform
a separate thefor each
Basic Module to help you supply the requested
patient
as Alarm date
Time of Patient information.
Transfer If you are using an auto-
mated system the data need to be entered
D Provider Impression/Assessment Check one box only only once, then they will be transferred automatically
None/no patient into
or refused treatment
other
10
modules that use the
Abdominal pain 18
data.Chest pain 26 Hypovolemia 34 Sexual assault
11 Airway obstruction 19 Diabetic symptom 27 Inhalation injury 35 Sting/bite
12 Allergic reaction 20 Do not resuscitate 28 Obvious death 36 Stroke/CVA
13 Altered LOC 21 Electrocution 29 OD/poisoning 37 Syncope
14 Behavioral/psych 22 General illness 30 Pregnancy/OB 38 Trauma
15 Burns 23 Hemorrhaging/bleeding 31 Respiratory arrest 00 Other
16 Cardiac arrest 24 Hyperthermia 6-432 Respiratory distress
17 Cardiac dysrhythmia 25 Hypothermia 33 Seizure
Age or Date of Birth Race Human Factors None Other

E1 F1 G1 Contributing to Injury G2 Factors
None
1 White
Section B: Number
A
of Patients and Patient Number MM DD YYYY
Month Day Ye
B C Time Arrived at Patient
Check if same date
as Alarm date
Use a separate form for each patient Time of Patient Transfer
D Provider Impression/Assessment Check one box only None/no patien

Record the total number of patients in the incident on the18first line of Section B. Remember
Chest pain 26
that you
Hypovolemia 34 S
10 Abdominal pain
need to fill out a separate form for11each patient. Enter
Airway obstructiona number
19 that identifies
Diabetic symptom each individual
27 patient
Inhalation injury 35 S
on line two. Assign patient numbers starting with 001.
12 Allergic reaction 20 Do not resuscitate 28 Obvious death 36 S
13 Altered LOC 21 Electrocution 29 OD/poisoning 37 S
14 Behavioral/psych 22 General illness 30 Pregnancy/OB 38 T
15 Burns 23 Hemorrhaging/bleeding 31 Respiratory arrest 00 O
16 Cardiac arrest 24 Hyperthermia 32 Respiratory distress
MM DD YYYY
Section C: Date/Time
17 Cardiac dysrhythmia 25 Hypothermia
Delete NFIRS–6
EMS
33 Seizure
Change
FDID State Incident Date Station Age
Incident or
Number Date of BirthExposure Race Human Factors None
E1 F1 G1 Contributing to Injury G2
Month 1Day
WhiteYear Hour/Min
C Time Arrived at Patient
Months (for infants)
2
3
Black, African American
Am. Indian, Alaska Native
Check all applicable boxes I
Check if same date Age 4 Asian 1 Asleep i
se a separate form for each patient
as Alarm date OR Transfer
Time of Patient 5 Native Hawaiian, Other 2 Unconscious
Pacific Islander Possibly impaired by alcohol
Provider Impression/Assessment None/no patientmultiracial
or refused treatment 3
Check one box only 0 Other,
Use the 18
first line to record Time Arrived
Chest pain
Month
26
at Patient.
Day Year
Hypovolemia
This is the
34
date and time when emergency person-
Sexual assault
U Undetermined 4 Possibly impaired by drug
Possibly mentally disabled
1
0 Abdominal pain 5 2
1 nel get 19
Airway obstruction to the Diabetic
same location
symptom as the 27 patient. This injury
Inhalation data element
35 is important
Sting/bite in situations where there 6 Physically disabled 3
E282 Gender F2 1Ethnicity Stroke/CVA
2 may be 20
Allergic reaction a significant amount of time
Do not resuscitate between the time an36
Obvious death emergency
Hispanic or unit
Latino arrives on the scene and 7 Physically restrained
3 Altered LOC 21 Electrocution 291 OD/poisoning
Male 2 Female 37
2 NonSyncope
Hispanic or Latino 8 Unattended person
4 the time22that direct
Behavioral/psych General contact
illness is made
30 with the patient.
Pregnancy/OB 38 Trauma
5 Burns 23 Hemorrhaging/bleeding 31 Body Respiratory
Site of Injury arrest 00 Other Injury Type
6 Cardiac arrest Examples:
24 Hyperthermia H
321 List upRespiratory
to five body sites distress
H2 List one injury type for each body site listed under H1

EMS personnel were prevented from approaching a patient because of a fire, criminal activity, or
Age or Date of Birth
F1 Race
Human Factors
1 other adverse conditions. G1 Contributing to Injury None
G2 Other
Factors
None
1 White
2 Black, African American
If an illness, not an
Check all applicable boxes
Responders
3 needAlaska
Am. Indian, to reach
Native an upper floor of a highrise building in order to gain access to a patient.
1 Asleep injury, skip G2 and
e 4 Asian
OR 5 Native Hawaiian, Other Unconscious go to H3
Enter the Time of Patient Transfer 23on Procedures
Pacific Islander the secondUsedline.byThis documents the date and time that patient Car
0 I
Other, multiracial
Possibly impaired alcohol
Check all applicable boxes No treatment
J Safety None K
nth Day Year care wasUtransferred from fire department
014
Undetermined Airwaypersonnel
Possibly impairedto
insertion by another
drug 14 care provider,
1 Intubation
Accidental or the time transporta-
(EGTA)
Equipment Chec
Possibly mentally
trousers disabled 15 2 Intubation
tion began to an emergency care02facility.
5
6
Anti-shock
Physically disabled
Self-inflicted
(ET) Used or deployed by patient.
Check all applicable boxes.
1 Pr
Gender Ethnicity Assist ventilation 16 3 IO/IV Inflicted, not self
2 F2 03
Physically restrained
therapy If pre-ar
1 Hispanic or Latino 047
Subtracting the Arrival at Patient time from the Transfer time provides an accurate reading
Bleeding control
1 of thebelts
Safety/seat 17 Medications therapy
1 Male 2 Female 2 Non Hispanic or Latino 058 BurnUnattended
care person 18 1
2 Child safety seat Oxygen therapy
actual time spent with the patient. 06 Cardiac pacing 3 Airbag 19 OB care/delivery 2
Body Site of Injury MM Injury
DD TypeYYYY
Cardioversion (defib) manual 20 Cause of NFIRS–6
H1 List up to five body sites A H2 List one 07 injury type for each body site listed under H1
HPrearrival
3 Illness/Injury instructions 4Delete Helmet 2 Po
08 Chest/abdominal thrust 21 Restrain patient EMS clothing
5Change Protective
09 CPR 22 Spinal immobilization 6 Flotation device Initial A
B Number of Patients
Section D: Provider Impression/Assessment
Patient Number 10
11
Cricothyroidotomy
Date/Time
CDefibrillation by AED Time Arrived at24
23 Splinted
Month extremities
Day
Cause of illness/injury
Patient Suction/aspirate
Year 0
U
Hour/Min
Other
Undetermined
1 V
12 Check
EKGif same date
monitoring 00 Other 0 O
as Alarm date
Use a separate form for each patient Time of Patient Transfer U U
13 Extrication
D Provider Impression/Assessment CheckInitial one box only
Highest Level of Care
None/no patient or refused treatment
Patient Status
L Level of
L None M EMS
Procedures Used 10 CheckAbdominal pain
all applicable boxes 18 treatment
No
1
ChestProvider
pain Safety
J Equipment 26 None
2 Provided
K
Hypovolemia Cardiac Arrest
On Scene 34 Sexual assault N Dispositio
1 Improved
all applicable boxes35
Airway insertion 11 Airway 14 obstructionIntubation 19
(EGTA) Diabetic
1 First Responder 27
symptom
1
Inhalation injury
Check
First Responder 36
Sting/bite
2 Remained same 1 FD tr
Anti-shock trousers12 Allergic15 reaction Intubation 20
(ET) Do2 not resuscitate
EMT-B
Used or(Basic) 28
deployed by patient.
2
Obvious death
1 Pre-arrival
EMT-B (Basic) arrest?
Stroke/CVA
3 Worsened 2 Non-
Assist ventilation 13 Altered 16 LOC IO/IV therapy 21 Electrocution
3 29
EMT-I (Intermediate) OD/poisoning 37 Syncope
3 IfEMT-I (Intermediate)
pre-arrival arrest, was it: 3 Non-
Bleeding control 14 Behavioral/psych
17 22 therapy
General
4 1 illness
EMT-P (Paramedic) 30 Pregnancy/OB 38 Check if:
Trauma
Medications Safety/seat belts 4 EMT-PWitnessed?
(Paramedic) 4 Non-
Burn care 15 Burns 18 23 Hemorrhaging/bleeding
0 Other provider 31 Respiratory1 arrest 00 1
Other Pulse on transfer
Oxygen therapy 2 Child safety seat 0 Other provider 0 Othe
Cardiac pacing 16 Cardiac 19 arrest 24 Hyperthermia
N 3 No Training 32 Respiratory2 distress CPR?
Bystander 2 No pulse on transfer
OB care/delivery Airbag
Cardiac
17 manual
Cardioversion (defib) 20 dysrhythmiaPrearrival 25 Hypothermia
instructions 33 Seizure
4 Helmet 2 Post-arrival arrest?
Chest/abdominal thrust 21 Restrain patient 5 Protective clothing
Age or Date of Birth Race Human Factors
CPR E1 22 SpinalFimmobilization
1 6 Flotation device G1 Contributing Initial Arrest
to Injury Rhythm
None
G2 Other
Factors
None
Cricothyroidotomy 23 1 White
Splinted extremities 0 Other
2 Black, African American 1 boxes V-Fib/V-Tach
Defibrillation by AED 24 (for infants)
Months Suction/aspirate U Alaska
Check all applicable If an illness, not an
3 Am. Indian, Undetermined
Native
EKG monitoring Age 00 Other 4 Asian 1 Asleep 0 Other injury, skip G2 and
Extrication
OR 5 Native Hawaiian, Other
Pacific Islander
2 6-5 U
Unconscious Undetermined go to H3
3 Possibly impaired by alcohol
0 Other, multiracial
Day Highest Year Level of Care Possibly
EMS impaired by drug
1
Initial Level of Month
L 2 Provided On Scene U None M Patient Status
Undetermined 4
NPossibly mentally disabled
Not transported 1 Accidental
Provider 5 Disposition 2 Self-inflicted
1 Improved
Record the single clinical assessment that most influenced the responder’s actions by marking one
of the coded boxes provided. If more than one choice applies to MM the patient,
DD
indicate the single most
YYYY
A
important clinical assessment that influencedFDIDthe plan ofStatetherapy and
Incident Date management. The Station box Incident
marked Number Exposure
should identify the actual assessment. This could be different from the original complaint that the Month
B Number of Patients Patient Number C Date/Time
unit responded to. Check if same date
Time Arrived at Patient
MM DD as Alarm date
YYYY
The assessment recorded on the form should
A provide the information needed to determine whether
the treatments or medications providedDmatched the protocols related to the clinical impression at
Provider
FDID Impression/Assessment
State Incident Date Check one box only Station Incident Number Non
Exposure
10 Abdominal 18 Number
pain Patient Chest painDate/Time 26 Hypovolemia Month 3D
the time of treatment. B11 Number of Patients
Airway obstruction 19 DiabeticCsymptom 27 Inhalation
Time Arrived injury
at Patient 3
Check if same date
12 Allergic reaction 20 Do not as resuscitate
Alarm date 28 Obvious death 3
13 Altered LOC 21 Electrocution 29 OD/poisoning 3
D14 ProviderBehavioral/psych
Impression/Assessment 22 General illness
Check one box only 30 Pregnancy/OB Non3
Section E: Age or Date of Birth, Gender 15

10
16
Burns
Abdominal
Cardiac arrest pain
23
18
24
Hemorrhaging/bleeding
Chest pain
Hyperthermia
31
26
32
Respiratory arrest
Hypovolemia
Respiratory distress 3
0
11 Airway
Cardiac obstruction
dysrhythmia 19
25 Diabetic symptom 27
33 Inhalation
Seizure injury 3
17 Hypothermia
12 Allergic reaction 20 Do not resuscitate 28 Obvious death 3
Age or Date of Birth Race Electrocution Human Factors 3
E13
1
14
Altered LOC
Behavioral/psych
F1 21
22 General illness
29
30
G1 ContributingOD/poisoning
Pregnancy/OB to Injury
N
3
1 White
15 Burns 23
2 Hemorrhaging/bleeding
Black, African American Respiratory
31Check all applicable boxes arrest 0
Cardiac arrest 3
24 Am.Hyperthermia
Indian, Alaska Native 32 Respiratory distress
16 1 Asleep
Age 4 Asian
17 OR dysrhythmia 25
Cardiac 5 Hypothermia
Native Hawaiian, Other 33
2
Seizure
Unconscious
Pacific Islander Possibly impaired by alco
Age or Date of Birth 3
F1 0URaceOther, multiracial Human Factors N
EMonth1 Day Year Undetermined
G4 1 Contributing
Possibly impaired to Injuryby drug
MM DD YYYY 1 White
2 Black, African American 5 Possibly mentally
Delete NFIRS–6
disable
A Gender Months (for infants)
3Ethnicity Am. Indian, Alaska Native
6 Physically disabled EMS
FDID State E
Incident
Age2
Date F2 41 Asian
Station Incident Number Exposure
17 Asleep
Change
Either enter the patient’s age or date of birth in Block E . You can record an infant’s age by marking
OR 1 5
Hispanic or Latino
Native Hawaiian, Other 28
Physically restrained
Unconscious
Unattended person
Number of Patients 1
Patient Number Male 2 Female
Date/Time 2 Non Hispanic
Islander or Latino
the Months box. B MM DD C
YYYY 0 Time
Pacific
Arrived
Other, at Patient
multiracial
3 Possibly impaired by alco
Delete NFIRS–6
4 Possibly impaired by drug
A Month
BodyDay Site Year Check if same date
of
H1DateList up to five body sites
Injury
as Alarm date
U Undetermined Injury Type
H2 Exposure Change EMS
Use aFDID
separate form for each patient
State Incident Station Time ofNumber
Incident Patient Transfer 5 type for Possibly
List one injury each body sitementally
listed under H1disable
6 Physically disabled
D Provider Impression/Assessment E2 Gender Date/TimeF2 1
Check one box only
Ethnicity
Month None/no Day patientYear or refused treatment
Hour/Min
B Number of Patients Patient Number C Female Hispanic or Latino
7 Physically restrained
Unattended person
10 Abdominal pain 18 1 Male 2
Chest pain Check if same date 226 NonHypovolemia
Hispanic or Latino 8
34 Sexual assault
11 a separate
Use Airwayform forobstruction
each patient 19 Diabetic as Alarm date
symptom 27 Inhalation
Time of Patient Transfer injury 35 Sting/bite
12 Allergic reaction 20 Body DoSitenotof Injury
resuscitate 28 Obvious death Injury Type 36 Stroke/CVA
Record the patient’s gender by marking the appropriate box.
D13 Provider Impression/Assessment H211 List upElectrocution
Check
to five one
bodybox only
sites 29 OD/poisoning
H2 List oneNone/no 37type patient
injury or refused
for each body
Syncope treatment
site listed under H1
Altered LOC
14 Behavioral/psych 22
18 General
Chest painillness 30
26 Pregnancy/OB
Hypovolemia 38
34 Traumaassault
Sexual
10 Abdominal pain
15
11
16
12
Airway Section F: Race, Ethnicity
Burns obstruction
Cardiac reaction
Allergic arrest
01
23 Procedures
19
24
20
I Hemorrhaging/bleeding
Diabetic
Hyperthermia
Do
Airway not
Used
symptom
resuscitate
insertion
31
27
Check all
32
28 14
Respiratory
Inhalation
applicable boxes
Respiratory
Obvious death
arrest
No treatment35
injury
distress
00
36
J
Other
Safety
Sting/bite
Equipment
Stroke/CVA
None
Intubation (EGTA)
17 CardiacLOC dysrhythmia 21 25 Hypothermia 33
29 Seizure 37
13 Altered 02 Electrocution
Anti-shock trousers 15 OD/poisoning
Intubation (ET) Syncope
Used or deployed by patient.
03 Race General
Assist illness
ventilation 30 16 Pregnancy/OB
IO/IV therapy 38 Check all applicable boxes.
Trauma
Age or Date of Birth Human Factors None Other
E
151 Burns F1 0423 Hemorrhaging/bleeding
Bleeding control 31G17 Respiratory
1 Contributing
Medications toarrest therapy 00 1 G2Other
Injury Safety/seat
Factors belts
None
Cardiac arrest 24 1 White
Hyperthermia 32 18 Respiratory distress
16 05 Burn care Oxygen therapy 2 Child safety seat
17 Cardiac dysrhythmia
Months (for infants) 25
06 I23 Procedures
Black, AfricanUsed
Am. Hypothermia
Cardiac
Indian, pacing
American Check all applicable
Alaska Native
Check boxes
33 19 all applicable
Seizure boxes
OB care/delivery
No treatment
J3 Safety If an illness,
Airbag
not anNone
Airway insertion 1 20 14 Asleep Equipment
injury, skip G2 and
Age 01
07 4 Asian
Cardioversion (defib) manual Intubation (EGTA)
Prearrival instructions 4
OR Helmet go tobyHpatient.
E1 Age or Date of Birth F1 02 5RaceNative Hawaiian,
Anti-shock Other
trousers 2 15 Human Factors (ET)
Unconscious None UsedOther 3
08 Chest/abdominal
Pacific Islander
Assist ventilation
thrust G 16
Intubation
121Contributing
Restrain
Possibly to patient
impairedInjury by alcohol
5 G2Check
or deployed
Protective
all applicableclothing
Factors boxes.
None
03
09 10 White
CPR multiracial 3 22 IO/IV therapy
Other, Spinal immobilization 6 Flotation device
04 2 Black, African
Bleeding American
control 4 17 Possibly boxesimpaired by drug 1 1If
Month Day Year(for infants)
Months 10 3U Am. Cricothyroidotomy
Undetermined
Indian, Alaska Native
Check Medications
23all applicable
Splinted therapy
extremities 0 an Accidental
Other illness,belts
Safety/seat not an
05 Burn care
Defibrillation by AED 5 18
1 24 Asleep Possibly
Oxygen mentally
therapy disabled 2 2 injury,
Child Self-inflicted
skip
safety G 2 and
seat
Age 11 4 Asian Suction/aspirate U Undetermined
OR Cardiac pacingOther 26 19 Physically disabled 3Airbag go to H3 not self
E2 Gender F20612 5 Ethnicity
Native
EKG Hawaiian,
monitoring OB
00 Unconscious
Other care/delivery 3 Inflicted,
Mark the box that in Block F to record the patient’s race, if known.
1 07
13 0
1 Pacific Islander
Cardioversion
Hispanic
Extrication
Other,
or Latino
multiracial
(defib) manual37 20 Possibly Physically
Prearrival restrained
impaired instructions
by alcohol4 Helmet
1 Male 2 Female 08 2 Chest/abdominal
Non Hispanic or thrust
Latino 48 21 Unattended
Restrain
Possibly person
impairedpatient by drug 5 1 Protective clothing
Month Day Year U Undetermined Accidental
09 Initial CPRLevel of 5 22 Possibly
Highest Spinal
Level immobilization
of mentally
Care disabled
M 6Patient 2 Status
Flotation device
Self-inflicted
Body Site of Injury L1 Provider
10 Cricothyroidotomy Injury L2 Type 6 23 Physically
Provided On Scene
Splinted
None
extremities Cause of N
EH21 Gender F2 1111Ethnicity Defibrillation by H
AED 2 List one injury 24
type
disabled
for each body site listed under H1 1
0
Improved H3Inflicted,
3 Other not self
Illness/Injury
List up to five body sites
First Responder 7 Suction/aspirate
Physically restrained U Undetermined
Hispanic or Latino 1 First Responder 2 Remained same 1
1 Male 2 Female 1222 EKG
EMT-B
Non
monitoring
(Basic)
Hispanic or Latino 8 00 Unattended Other person
2 EMT-B (Basic) 3 Worsened 2
133 Extrication
EMT-I (Intermediate) 3
EMT-I (Intermediate) Cause of illness/injury
3
Check if: Cause of
Body Site of Injury 4 EMT-P (Paramedic) Injury Type
F2 identifies the ethnicity of the patient. Ethnicity is an ethnic classification or affiliation. Currently
H1 List up to five body sites H2 List one injury
4 Highest EMT-P Level (Paramedic)
of listed
Care under H1None M 1 Patient H
PulseStatus 3 4
L01 Initial
Provider
Level
Other of
provider L02 Providedtype for each
OtherOn
body site
provider
Scene
Illness/Injury
on transfer
N 0
Hispanic is the only U.S. Census Bureau classification. Hispanic is not considered a race because a
N No Training 12 No pulse on transfer
Improved
1 First Responder 1 2 Remained same 1
person can be black and Hispanic, white and Hispanic, etc. 2 EMT-B (Basic) 2
First Responder
EMT-B (Basic) 3 Worsened Cause of illness/injury 2
I Procedures Used Check3all applicable
EMT-I
boxes (Intermediate) No treatment
3 JEMT-ISafety
(Intermediate) NoneCheck K if:
Cardiac Arrest 3
Airway insertion 4 14EMT-PIntubation
(Paramedic) Equipment Check all applicable boxes 4
01 (EGTA) 4 EMT-P (Paramedic)
0 1 Pulse on transfer
02 Anti-shock trousers 15Other provider
Intubation (ET) 0 OtherUsed provider
or deployed by patient.
1 Pre-arrival arrest? 0
03 Assist ventilation N 6-6
16No Training IO/IV therapy
Check all applicable boxes. 2 No pulse on transfer
If pre-arrival arrest, was it:
04I Procedures
Bleeding control Used 17 boxes Medications
Check all applicable No treatment
therapy J1 Safety/seat belts None K Cardiac Arrest
Safety
1 Check Witnessed?
05 Burn care
Airway insertion 18
14 Oxygen therapy 2 Equipment
Child safety seat all applicable boxes
01 Intubation (EGTA)
06 Cardiac pacing 19 OB care/delivery 3 2 Bystander CPR?
02 Anti-shock trousers 15 Intubation (ET) Airbag
1 Pre-arrival arrest?
Delete
A Incident Date Change EMS
FDID State Station Incident Number Exposure
Number of Patients Patient Number Date/Time NFIRS 5.0 Self-StudyMonth

ProgramDay Year Hour/Min
Check if same date
as Alarm date
These data are useful for epidemiological studies, and also can be important in accessing certain
D Provider Impression/Assessment Check one box only None/no patient or refused treatment
types of Federal or State funds directed to specific racial or ethnic groups.
10 Abdominal pain 18 Chest pain 26 Hypovolemia 34 Sexual assault
13
14
Altered LOC
Behavioral/psych
Section G: Human Factors Contributing to Injury
21
22
Electrocution
General illness
29
30
OD/poisoning
Pregnancy/OB
37
38
Syncope
Trauma
15
16
Burns
Cardiac arrest
23
24 and Other Factors
Hyperthermia
31
32
Respiratory arrest
Respiratory distress
00 Other

E1
MM DD YYYY
F1 G1 Contributing to Injury G2 Factors
None
1 White Delete NFIRS–6
2 Black, African American EMS
3 Am. Number
Indian, Alaska Native Change If an illness, not an
cident Date Station Incident Exposure
Age 4 Asian 1 Asleep injury, skip G2 and
OR 5 Native Hawaiian, Other Month
2
Day Unconscious
Year Hour/Min go to H3
ent Number
C Date/Time Pacific Islander
3
Time Arrived at Patient Possibly impaired by alcohol
Check if same date
Month Day Year
as Alarm date U Undetermined 4 Possibly impaired by drug 1 Accidental
Time of Patient Transfer
5 Possibly mentally disabled 2 Self-inflicted
sment Gender Ethnicity 6 patient
None/no Physically
or refused disabled
treatment 3 Inflicted, not self
E2 Check one box only
F2 1 7 Physically restrained
Hispanic or Latino
18 1 Chest 2painFemale
Male 26
2 NonHypovolemia
Hispanic or Latino
34
8 Sexual assault
Unattended person
19 Diabetic symptom 27 Inhalation injury 35 Sting/bite
20 Body Do Site
not resuscitate
of Injury 28 Obvious death Injury Type 36 Stroke/CVA Cause of
H
211 List up
Electrocution
to five body sites
Use Block G to clarify patient circumstances that may have contributed to the injury/illness. Mark
291 OD/poisoning H2 List one 37 type
MM injury Syncope
DDfor each body
YYYYsite listed under H1
H3 Illness/Injury
NFIRS–6
Delete
22 General illness as many boxes as are applicable. This information can be important to injury researchers who Change
A 30 Pregnancy/OB 38 Trauma plan EMS
23 Hemorrhaging/bleeding 31 FDID Respiratory arrest Incident00
State Date
Other Station Incident Number Exposure
24 Hyperthermia injury-reduction programs based on human factors.

32 Respiratory distress Cause of illness/injury
25 Hypothermia B 33 Number of Patients
Seizure Patient Number
C Date/Time Time Arrived at Patient
Check if same date
Race Human Factors None Other
as Alarm date
G
Use a separate
1 form for each patient
Contributing to Injury G2 Factors
None Time of Patient Transfer
1 White
Procedures UsedNative D Provider
Check Impression/Assessment
all applicable boxes
Check one box only
If an illness, not an
Safety Cardiac Arrest
None/no patient or refused treatment
3 I Am. Indian, Alaska Check all applicable boxes
Asleep
No treatment
J injury, skip G2 and 26
None K
4
01 Asian
Airway insertion 10 1 14 Abdominal pain
Intubation (EGTA) 18 Chest Equipment
pain Hypovolemia
Check all applicable boxes 34 Sexual assault
5 Native Hawaiian, Other 11 2 15 Airway Unconscious 19 Diabetic go to H3 27 Inhalation injury 35 Sting/bite
02 Anti-shock trousers obstruction
Intubation (ET) Used or symptom
deployed by patient. Pre-arrival arrest?
Pacific Islander Possiblyreaction
3 16 Allergic impaired by alcohol 1 36
030 Assist
Other, ventilation
multiracial 12 IO/IV therapy 20 Do not
Checkresuscitate
all applicable boxes. 28 Obvious death Stroke/CVA
Possibly impaired by drug If pre-arrival arrest, was it:
04U Undetermined
Bleeding control 13 4 17 Altered LOC
Medications therapy 21 1
Electrocution Accidental 29 OD/poisoning 37 Syncope
1 Safety/seat belts
14 Possibly mentally disabled
5 18 Behavioral/psych 22 2
General Self-inflicted
illness 30 1 Pregnancy/OB
Witnessed? 38 Trauma
05 Burn care Oxygen therapy 2 Child safety seat
15 6 19 Burns Physically disabled 3 Inflicted, not self 31 00
2 06
EthnicityCardiac pacing OB care/delivery 23 3
Airbag
2 Respiratory
Bystander arrest
CPR? Other
16 7 20 Cardiac Physically arrest restrained 24 Hyperthermia 32 Respiratory distress
071 Hispanic or Latino
Cardioversion (defib) manual Prearrival instructions 4 Helmet Post-arrival arrest?
082 thrust 17 8 21 Cardiac
Non Hispanic or Latino
Chest/abdominal
Unattended person
dysrhythmia
Restrain patient 25 Hypothermia 33 2 Seizure
09 CPR Use Block G to address other factors such as accidental, self-inflicted, or inflicted, not self that affect
2 22
Spinal
5 Protective clothing
Initial Arrest Rhythm
Age or Date of immobilization
Birth Race6 Flotation device Human Factors
10 Cricothyroidotomy how the injury/illness occurred. Data can be used to show number comparisons between accidental
Injury 1Type23
H2 List oneEinjury Splinted F
extremities
type for each body site listed under H1
1 0 H 3
Other
Cause of
Illness/Injury
G 1 Contributing to Injury
None
G2 Other Factors
None
Defibrillation by AED 24 1 White 1 V-Fib/V-Tach
11
12 EKG monitoring
and self-inflicted incidents. Suction/aspirate 2 U
Black, Undetermined
African American Check0 all applicable
Other boxes If an illness, not an
00 Other
3 Am. Indian, Alaska Native
13 Extrication Age 4 Asian 1 U Asleep Undetermined injury, skip G2 and
OR 5 Native Hawaiian, Cause of illness/injury
Other 2 Unconscious go to H3
Pacific Islander
Highest Level of Care Patient Status 3EMS Possibly impaired by alcohol
Initial Level of
L1 Provider LMonth None 0 M Other, multiracial Not transported
N 4Disposition
Section H: Body Site of Injury, Injury Type,
2 Provided On Scene Possibly impaired by drug
Day Year U 1 Undetermined 1 Accidental
Improved
1 First Responder 5 Possibly mentally disabled 2 Self-inflicted
1 First Responder 2 Remained same 1 FD transport to ECF
and Cause of Injury/Illness

Physically disabled
2 EMT-B (Basic) 2E Gender
EMT-B (Basic) F 2
Ethnicity
3 Worsened 26 Non-FD transport 3 Inflicted, not self
2 Safety Cardiac Arrest
No treatment
J 1 K Hispanic or Latino
eck all applicable boxes Physically restrained
3 EMT-I (Intermediate) None 3 7 Non-FD trans/ FD attend
3 EMT-I (Intermediate)
4 14 EMT-PIntubation (EGTA)4 1
(Paramedic) Male Equipment
2 Female 2
Check if: Check all applicable boxes
Non Hispanic or Latino 48
Unattended person
Non-emergency transfer
EMT-P (Paramedic) 1
0 15 OtherIntubation
provider (ET) 0 Used or deployed by patient. Pulse on transfer
Pre-arrival arrest? 0 Other
Other provider 1
N 16 No Training IO/IV therapy
Body Site of Injury 2 No pulse on transfer Injury Type Cause of
17
H1 List up to five body sites If pre-arrival arrest, wasHit:2 List one injury type for each bodyNFIRS–6 Revision 01/01/04
H3 Illness/Injury
Medications therapy 1 Safety/seat belts
18 1 Witnessed?
Oxygen therapy 2 Child safety seat
19 OB care/delivery 3 2 Bystander CPR?
Airbag
nual 20 Prearrival instructions 4 Helmet 2 Post-arrival arrest?
21 Restrain patient 5 Protective clothing
22 Spinal immobilization 6 Flotation device Initial Arrest Rhythm
23 Splinted extremities 0 Other
24 Suction/aspirate 1 V-Fib/V-Tach
U Undetermined
Procedures Used 0 boxesOther Cardiac Arrest
00 Other I Check all applicable
U Undetermined
No treatment
J Safety Equipment
None K
01 Airway insertion 14 Intubation (EGTA) Check all applicable boxes
02 Anti-shock trousers 15 Intubation (ET) Used or deployed by patient.

Highest Level of Care Patient Status
03M Assist ventilation EMS Check all applicable boxes.
L2 Provided On Scene None
N 16
Disposition
Not transported
IO/IV therapy If pre-arrival arrest, was it:
17
1 First Responder
04 1 Bleeding
05 2 Burn
Improved control
care same
Remained 1 18 FD transport Oxygen to
6-7
Medications therapy
ECF
therapy
1
2
Safety/seat belts
Child safety seat
1 Witnessed?
2 EMT-B (Basic) 06 3 Cardiac
Worsened pacing 2 19 Non-FD transport
OB care/delivery 3 2 Bystander CPR?
Airbag
3 EMT-I (Intermediate) 07 CheckCardioversion (defib) manual 3 20 Non-FD trans/FDinstructions
Prearrival attend 4 Helmet
if: 2 Post-arrival arrest?
4 EMT-P (Paramedic) 08 Chest/abdominal thrust 4 21 Non-emergency Restrain patient transfer 5 Protective clothing
19 Diabetic symptom 27 Inhalation injury 35 Sting/bite
20 Do not resuscitate 28 Obvious death 36 Stroke/CVA
21 Electrocution 29 OD/poisoning 37 Syncope
22 General illness 30 Pregnancy/OB 38 Trauma
23 Hemorrhaging/bleeding 31 Respiratory arrest 00 Other
24 Hyperthermia 32 Respiratory distress NFIRS 5.0 Self-Study Program
25 Hypothermia 33 Seizure
Race You can record up toFactors

Human
G1 Contributing five body sitesNone
in Block H1. Describe
G2 Other the body site injured and its corresponding
None
to Injury Factors
1
2
White
injury type,Checklisting the body site with the most serious injury first. H2 links the type of each injury
all applicable boxes If an illness, not an
3
4
noted to each
Asian 1
body
Asleepsite. injury, skip G2 and
5 Native Hawaiian, Other 2 Unconscious go to H3
Pacific IslanderSite and type
3 of injury
Possibly are crucial
impaired by alcoholdata elements that will enable EMS planners to identify the
U Undetermined types of injuries
4 experienced
Possibly impaired bybydrug
patients1 using the EMS system. These data also are used to analyze
Accidental
Ethnicity
the correlation
6
betweendisabled
Physically injury assessment 3
inInflicted,
the field and actual injuries as evaluated in medical
not self
1 receiving
Hispanic or Latino facilities.
7 Physically restrained
2 Non Hispanic or Latino 8 Unattended person
Injury Type Cause of

H3 Illness/Injury
Enter a code in Block

Safety
H3 to capture the Cardiac specificArrest cause of the illness/injury. Data analysis provides an
None K
No treatment
all applicable boxes
J
understanding ofEquipment
the conditions causing the injury.
14 Check all applicable boxes It also assists with planning treatments in the
Intubation (EGTA)
15 field
Intubation (ET)and developing illness/injury
programs.
16 IO/IV therapy If pre-arrival arrest, was it:
17 Medications therapy 1 Safety/seat belts
18 1 Witnessed?
19 Cause of Illness/Injury
OB care/delivery 3 Codes
Airbag
2 Bystander CPR?
ual 20 Prearrival instructions 4 Helmet 2 Post-arrival arrest?
21
10 Chemical
Restrain patient 5 Exposure
Protective clothing 20 Heat 31 Non-traffic vehicle (off-road)
22 Spinal immobilization 6
11 Drug Poisoning
Flotation device 21 Initial
Explosives
Arrest Rhythm accident
23 Splinted extremities
24 12 Fall U
Suction/aspirate
0 Other 22 1 FireV-Fib/V-Tach
and flames 32 Physical assault/abuse
Undetermined
00 Other 13 Aircraft related 23 0 Firearm
Other 33 Scalds/other thermal
14 Bite, includes animal bites 25 U Fireworks
Undetermined 34 Smoke inhalation
26 Lightning 35 Stabbing assault
Highest Level of Care15 Bicycle accident
None M
Patient Status
N 27 Machinery Not transported 36 Venomous sting
EMS
Provided On Scene 16 Building collapse/construction Disposition
1
accident
Improved
1
28 Mechanical suffocation
FD transport to ECF
37 Water transport
First Responder 2 Remained same
EMT-B (Basic) 17 Drowning
3 Worsened 229 Motor vehicle
Non-FD accident
transport 00 Other cause
18 Electrical
EMT-I (Intermediate) shock 330 Motor vehicle
Non-FD accident,
trans/FD attend UU Unknown
Check if:
19 Cold1
EMT-P (Paramedic)
Pulse on transfer
4 pedestrian
Non-emergency transfer
Other provider 0 Other
2 No pulse on transfer NFIRS–6 Revision 01/01/04
Example:
Patient with two stab wounds in different body sites and a blunt trauma injury to another body site.
Block H1 Block H2 Block H3

(2) neck and shoulder (18) puncture/stab (35) stabbing
(7) lower extremities (18) puncture/stab (35) stabbing
(1) head (11) blunt injury (13) assault
The system captures each separate injury related to a particular body site for as many as five injuries.
6-8
A Incident Date
1 Male 2 Female 2 Non Hispanic or Latino Change8 EMS
Unattended person
Body Site of Injury YearInjury Type Cause

B Number of Patients Patient Number
CH Date/Time
1 List up to five body sites
Month Day
H2
Hour/Min
List one injury type for each body site listed under H1
H3 Illnes
Check if same date
as Alarm date
Cause of illnes
10 Abdominal pain 18 Chest pain Section I: Procedures Used

26 Hypovolemia 34 Sexual assault
13 Altered LOC 21 Electrocution Procedures 29Used OD/poisoning 37 NoSyncope Cardiac Arrest
I
General illness Airway insertion 30
Pregnancy/OB 38
treatment
Trauma
J Safety Equipment
None K
01 14 Intubation (EGTA) Check all applicable bo
15 Burns 23 Hemorrhaging/bleeding 31trousers Respiratory arrest 00 Other
02 Anti-shock 15 Intubation (ET) Used or deployed by patient.
1 Pre-arrival arr
16 Cardiac arrest 24 Hyperthermia Assist ventilation 32 Respiratory distress 16
03 IO/IV therapy If pre-arrival arrest, was i
17 Cardiac dysrhythmia 25 Hypothermia 33 Seizure 17
04 Bleeding control Medications therapy 1 Safety/seat belts
1 Witnessed
Age or Date of Birth Race 05 Burn care Human Factors 18 Oxygen
None therapy Other 2 Child safety seat
E1 F1 06 Cardiac pacing G1 Contributing to Injury 19 G2 Factors 3
OB care/delivery
None
Airbag
2 Bystander
1 White
2 07
Cardioversion (defib) manual 20 Prearrival instructions 4 Helmet
Check all applicable boxes If an illness, not an 2 Post-arrival a
3 08 Native
Am. Indian, Alaska Chest/abdominal thrust 21 Restrain patient 5 Protective clothing
Age 4 Asian CPR 1 Asleep 22 injury, skip G 2 and
OR 09 Spinal immobilization 6 Flotation device Initial Arrest Rhyth
5 Native Hawaiian, Other 2 Unconscious 23 go to H3
10 Cricothyroidotomy Splinted extremities 0 Other
Pacific Islander Possibly impaired
0 11
Other, multiracial Defibrillation 3 by AED 24 by alcohol
Suction/aspirate U Undetermined
1 V-Fib/V-Tach
Month Day Year U Undetermined12 EKG monitoring 4 Possibly impaired by drug 1 Accidental 0 Other
00 Other
13 Extrication5 Possibly mentally disabled 2 Self-inflicted U Undetermin
6 Physically disabled 3 Inflicted, not self
E2 Gender F2 1Ethnicity 7 Physically restrained
Hispanic or Latino
L1 Initial Level of
L2 Provided None M EMS
1 Male 2 Many possible procedures are listed in Section I. Procedures are defined as anything done to assess or
Female 2 Non Hispanic or Provider
Latino 8 Unattended person On Scene N Disposition Not t
1 Improved
treat the patient. Mark all applicable boxes to document the procedures either attempted or actually
1 First Responder 1 First Responder 2
Cause ofRemained same
1 FD transport to
Body Site of Injury Injury(Basic)
Type
H1 List up to five body sites 2 H2 EMT-B
performed during the course of patient care. 2 EMT-B
List one injury type for each body site listed under H1 (Basic) H 3 3
Illness/InjuryWorsened 2 Non-FD transpo
3 EMT-I (Intermediate) 3 3 Non-FD trans/FD
EMT-I (Intermediate) Check if:
4 EMT-P (Paramedic) 4 4 Non-emergency
EMT-P (Paramedic) 1
0 Other provider Pulse on transfer 0 Other
0 Other provider Cause of2
illness/injury
N No Training No pulse on transfer NFIRS–6 Rev
Section J: Safety Equipment

Procedures Used Safety Cardiac Arrest
I Check all applicable boxes No treatment
J None K
Airway insertion 14 Equipment Check all applicable boxes
03 Assist ventilation 16 IO/IV therapy If pre-arrival arrest, was it:
04 Bleeding control 17 Medications therapy 1 Safety/seat belts
05 Burn care 18 1 Witnessed?
Airbag
07 Cardioversion (defib) manual 20 Prearrival instructions 4 Helmet 2 Post-arrival arrest?
08 Chest/abdominal thrust 21 Restrain patient 5 Protective clothing
09 CPR 22 Spinal immobilization 6 Flotation device Initial Arrest Rhythm
10 Cricothyroidotomy 23 Splinted extremities 0 Other
11 Defibrillation by AED 24 Suction/aspirate 1 V-Fib/V-Tach
U Undetermined
12 EKG monitoring 00 Other 0 Other
13 Extrication U Undetermined
If the patientHighest
was Level
usingof Care
any safety equipment at the time of EMS
Patient Status
the injury record a description of the
L1 Initial Level of None M
type usedL2inProvided
Not transported
Provider SectionOnJ.Scene N Disposition
1 Improved
1 First Responder 1 2 Remained same 1 FD transport to ECF
First Responder
2 EMT-B (Basic) Nine options
2 are provided. These data
EMT-B (Basic) 3 provide important information
Worsened 2 Non-FDabout whether or not appro-
transport
3 EMT-I (Intermediate)
4
priate safety
EMT-P (Paramedic)
3 devices are being used.Check
EMT-I (Intermediate) This
if: is especially important
3 in
Non-FDindustrial and motor vehicle
trans/FD attend
4 EMT-P (Paramedic) 4 Non-emergency transfer
0 Other provider incidents,0 which are regulated by FederalPulse
Other provider
1 agencies and local0and State
on transfer Other laws.
N No Training 2 No pulse on transfer NFIRS–6 Revision 01/01/04
Researchers, consumer groups, and manufacturers use these data to study the effectiveness of safety devices
in preventing injuries and reducing deaths. This information also is important to use when improvements
are being made to existing safety devices, or when new safety devices are being developed.
6-9
2 Non Hispanic or Latino 8 Unattended person D Provider Impression/Assessment Check one box only None
10 Abdominal pain 18 Chest pain 26 Hypovolemia 34

Injury Type Cause of
11 HAirway obstruction
3 Illness/Injury 19 Diabetic symptom 27 Inhalation injury 35
12 Allergic reaction 20 Do not resuscitate 28 Obvious death 36
NFIRS
13 5.0Altered
Self-Study LOCProgram 21 Electrocution 29 OD/poisoning 37
14 Behavioral/psych 22 General illness 30 Pregnancy/OB 38
15 Burns 23 Hemorrhaging/bleeding 31 Respiratory arrest 00
Section K: Cardiac Arrest

MM
16
17 DD
Cardiac
Cardiac
YYYY
arrest
dysrhythmia
24
25
Hyperthermia
Hypothermia
32
33
Respiratory distress
Seizure
Delete NFIRS–6
A Age or Date of Birth EMS
F1 Race
Human Factors
Change No
FDID
Safety
State E1 Cardiac
Incident Date
Arrest
Station Incident Number Exposure
G1 Contributing to Injury
None K
No treatment
J Equipment
1 White
14 Intubation (EGTA) Number of Patients Patient Number Check all applicable Date/Time
boxes 2 Black, African American
15
B C Months (for infants)
3TimeAm. Indian,
Arrived Alaska Native
at Patient
Intubation (ET) Used or deployed by patient.

1
Age Pre-arrival arrest?
Check if same date 4 Asian 1 Asleep
16 IO/IV therapy
Check all applicable boxes. OR as Alarm date 5TimeNative Hawaiian, Other 2 Unconscious
Use a separate form for each patient If pre-arrival arrest, was it: of Patient Transfer
17 Medications therapy Pacific Islander Possibly impaired by alcoh
1 Safety/seat belts 3
1 Witnessed? 0 Other, multiracial
18 Oxygen therapy D 2 Provider
ChildImpression/Assessment
safety seat Month
Check one box only
Day Year U Undetermined
None/no patient
4 or refused
Possibly treatment
impaired by drug
19 OB care/delivery 2 Bystander CPR? Possibly
103 Airbag
Abdominal pain 18 Chest pain 26 Hypovolemia 345 Sexual assault disabled
mentally
manual 20 Prearrival instructions 4 Physically
11 Helmet
Airway obstruction 19 Gender
E22 Post-arrival
Diabetic symptom arrest?
F2 Ethnicity
27 Inhalation injury 356 Sting/bitedisabled
st 21 Restrain patient Physically restrained
125 Protective
Allergic reactionclothing 20 Do not resuscitate 1
28 Hispanic
Obviousor death
Latino 367 Stroke/CVA
22 Spinal immobilization 6 Initial Arrest Rhythm Unattended
13 Flotation
Altered LOC device 21 1 Male
Electrocution2 Female 2
29 Non Hispanic or Latino
OD/poisoning 378 Syncope person
23 Splinted extremities
140 Other
Behavioral/psych 221 General
V-Fib/V-Tach illness 30 Pregnancy/OB 38 Trauma
24 Suction/aspirate
15U Undetermined
Burns 23
H
Body Site of Injury
0 1 ListOther 31 Respiratory arrest Injury00Type
H2 List one injury Other
00 Other up to five body sites type for each body site listed under H1
16 Cardiac arrest 24U Hyperthermia
Undetermined 32 Respiratory distress
Highest Level of Care None M
Patient Status EMS
L2 Provided On SceneThis section is Eused
1
Age or Date of Birth
to indicate if patient
N Race
F1 Disposition Not transported
cardiac arrest was pre-Gor Human Factors
postarrival
1 Contributing on the scene
None
Gof2 an
Other None
1 Improved 1 White
to Injury Factors
1 incident. If it2 occurred
First Responder Remainedpre-arrival,
same you
1 2 should
FD indicate
transport
Black, African to ECFwhether Check
American
or allnot it was witnessed and/orIf an
applicable boxes
if illness, not an
2 3 Non-FD
2 bystanders performed
EMT-B (Basic) 3 Age CPR.
Worsened
4 Asian
transport
1 Asleep injury, skip G2 and
3 EMT-I (Intermediate) Check if:
3 OR
Non-FD trans/FD attend 5 Native Hawaiian, Other 2 Unconscious go to H3
4 Procedures
IslanderUsed
Non-emergency transfer Check all applicable boxes Safety
4 EMT-P (Paramedic) You also should
1 record
Pulse on the initial arrest
transfer I rhythm
Pacific
0 Other
by checking
Other, multiracial
the3 boxPossibly next to either byV-Fib/V-Tach,
No treatment
impaired alcohol J None
0 Other provider 0 01 Airway insertion 14 Equipment
4 Possibly impaired
Intubation by
(EGTA)drug 1
Other, or Undetermined.
2 Month No pulse
Day on transfer
Year U
02
Undetermined
Anti-shock trousers
NFIRS–6 Revision 01/01/04
5 15 Possibly mentally
Intubation disabled
(ET)
Accidental
2 Used orSelf-inflicted
deployed by patient.
Gender 03 Assist ventilation3 6
Inflicted, not self 16 Physically disabled
IO/IV therapy
Data from thisEsection
2 F2 041Ethnicity
are used to evaluate prehospital
Bleeding CPR and the7 effect
control ofMedications
cardiac
17 Physically care
restrained on reducing
therapy 1 Safety/seat belts
Hispanic or Latino
morbidity. 1 Male 2 Female 05
2 Burn care or Latino
Non Hispanic 8 18 Unattended
Oxygenperson
therapy 2 Child safety seat
06 Cardiac pacing 19 OB care/delivery 3 Airbag
Body Site of Injury 07 Cardioversion (defib) manual
Injury Type20 Prearrival instructions 4 HelmetCause of
H1 08 Chest/abdominal H2thrust
List one injury type21 Restrain
for each body patient
site listed under H1 5
H 3 Illness/Injury
List up to five body sites Protective clothing
Section L: Initial Level of Provider and 09
10
CPR
Cricothyroidotomy
22
23
Spinal immobilization 6
Splinted extremities 0
Flotation device
Other
Highest Level of Care Provided on Scene 11

12
Defibrillation by AED
EKG monitoring
24
00
Suction/aspirate
Other
U Cause of illness/injury
Undetermined
13 Extrication
Highest Level of Care

L1 Initial Level of
L2 ProvidedSafety
On Scene
None M Patient Status N
E
Procedures Used Provider Cardiac Arrest D
I 1
First Responder
No treatment
J None 1 K Improved
01 Airway insertion 14 Intubation (EGTA) 1 FirstEquipment
Responder 2 Remained same
Check all applicable boxes 1
2 EMT-B (Basic) 2 3 Worsened 2
02 Anti-shock trousers 15 Intubation (ET) EMT-B (Basic)
3 EMT-I (Intermediate) 3 Check all applicable boxes. 3
03 Assist ventilation 16 IO/IV therapy EMT-I (Intermediate) CheckIfif:pre-arrival arrest, was it:
4 EMT-P (Paramedic) 4 4
04 Bleeding control 17 Medications therapy 1 EMT-P (Paramedic)
Safety/seat belts 1
0 Other provider 1 Pulse on transfer
Witnessed? 0
05 Burn care 18 Oxygen therapy 0 2 OtherChild
providersafety seat 2 No pulse on transfer
N No Training 2 Bystander CPR?
06 Cardiac pacing 19 OB care/delivery 3 Airbag
Block L1 is used to collect data about the training level of the fire department responders who
09 CPR 22
provided the initial care. Researchers can use these data to determine the effectiveness of Initial
10 Cricothyroidotomy 23 care Arrest
and Rhythm
Spinal immobilization 6
Splinted extremities 0
Flotation device
Other
measure any trends in the quality of prehospital care being provided by fire departments. 1
11 Defibrillation by AED 24 V-Fib/V-Tach
Suction/aspirate U Undetermined

L1 Initial Level of
L2 Provided On Scene
None M N
EMS Not transported
Provider Disposition
1 Improved
First Responder
2 EMT-B (Basic) 2 3 Worsened 2 Non-FD transport
EMT-B (Basic)
3 EMT-I (Intermediate) 3 3 Non-FD trans/FD attend
4 EMT-P (Paramedic) 4 4 Non-emergency transfer
EMT-P (Paramedic) 1
0 Other provider 2
N No Training No pulse on transfer NFIRS–6 Revision 01/01/04
6-10
23 Hemorrhaging/bleeding 31 Respiratory arrest 00 Other
24 Hyperthermia 32 Respiratory distress
mia 25 Hypothermia 33 Seizure
F1 RaceProcedures Used G
Human Factors
1 Contributing NFIRS
None 5.0 Self-Study
G2 Other Program None
Cardiac Arrest
1I White
Check all applicable boxes No treatment
to Injury J Safety
Factors
Equipment
None K
2
01 Airway
Black, insertion
African American Check 14all applicable
Intubation
boxes (EGTA) If an illness, not an
3 Am. Indian, Alaska Native 15 Asleep
Anti-shock trousers
02
4 Asian
Assist
Block L is used to gather training-level information on the fire department
ventilation
2 1
16 Unconscious
Intubation (ET) 1 Pre-arrivalresponders
injury, skip by
Used or deployed
arrest? who pro-
Gpatient.
2 and
03
5 Native Hawaiian, Other 2 IO/IV therapy go to H 3
Bleeding
04 Pacific Islandervided the highest level of care at the scene of an incident. This knowledge can help determine what
control 3
17 Possibly Medications
impairedtherapy
If pre-arrival arrest, was it:
by alcohol 1 Safety/seat belts
0
05
U
Other,
Undetermined kind of effect there is on patient care in the field when responders 12haveWitnessed?
Burnmultiracial
care 4
18 Possibly Oxygen impairedtherapy by drug 2 1 Child higher levels of training/
safety seat
Accidental
Bystander CPR?
06 Cardiac pacing 19 Possibly OB care/delivery
mentally disabled 3 2 Airbag
07 certification.
Cardioversion (defib) manual
5
20 Physically Prearrival instructions 4 3 Helmet
disabled
Self-inflicted
6 Inflicted, not self Post-arrival arrest?
F2 081Ethnicity
Chest/abdominal thrust 7
21 Physically Restrain patient
restrained 5 Protective clothing
2
Hispanic or Latino
09 CPR 22 Unattended Spinal immobilization
person 6 Flotation device Initial Arrest Rhythm
2 Non Hispanic or Latino 8
Section M: Patient Status

Injury Type U Cause of
Undetermined
12 EKG monitoring H2 List one injury type00for each body
Other
0 H3 Illness/Injury
Other
Initial Level of Highest Level of Care None M

Patient Status EMS
L1 Provider
L2 Provided On Scene Cause of illness/injury
N Disposition
Not transported
1 Improved
First Responder
EMT-B (Basic)
4 EMT-P (Paramedic) 4 Safety Cardiac Arrest 4 Non-emergency transfer
0 Other provider
No treatment
JEMT-P (Paramedic)
Equipment
None 1 K Pulse on transfer
0 Other
0 Other provider
N 14 No Training
Intubation (EGTA) 2 No pulse on transfer NFIRS–6 Revision 01/01/04
15 Intubation (ET) Used or deployed by patient.
16 IO/IV therapy If pre-arrival arrest, was it:
17 Mark the box that indicates whether the patient Improved, Remained same, or Worsened while
Medications therapy 1 Safety/seat belts
18 1 Witnessed?
19
under fire department care. This determination is made at the time of patient transfer. There is also a
2 Bystander CPR?
OB care/delivery 3 Airbag
b) manual 20 box that should be marked whether or not the patient had a pulse on transfer.
Prearrival instructions 4 Helmet Post-arrival arrest?
2
rust 21 Restrain patient 5 Protective clothing
22 Spinal immobilization 6 Flotation device Initial Arrest Rhythm
23 Splinted extremities 0 Other
Section N: Disposition
D 24 Suction/aspirate 1 V-Fib/V-Tach
U Undetermined
00 Other 0 Other
U Undetermined

None M N
EMS Not transported
Disposition
1 Improved
1 First Responder 2 Remained same 1 FD transport to ECF
2 EMT-B (Basic) 3 Worsened 2 Non-FD transport
e) 3 3 Non-FD trans/FD attend
) 4 4 Non-emergency transfer
EMT-P (Paramedic) 1 Pulse on transfer 0 Other
0 Other provider 2 No pulse on transfer NFIRS–6 Revision 01/01/04
There are six choices available for documenting the disposition of the patient. These data will allow
generation of reports that show the disposition for EMS responses, and can correlate various patient
treatments to patient outcomes. This section may help the fire service to look at what its EMS trans-
port needs are.
SUMMARY
Nationally, EMS activities are a significant part of the total service being provided by fire departments.
The fire service can use the EMS Module to report all emergency medical incidents to which a fire
department unit responds. A separate EMS Module is used for each patient.
6-11
EXAMPLE: Injured Person

Directions: Read the call information in the example below.Then look at the completed EMS Module form. Look at each section
and follow along with the proper use of the information as applicable to the EMS Module.
Department FDID #TR200, Station #1, is dispatched on a medical call on May 1, 2002. A fire
department unit is dispatched to respond to the call at 0223 hours. The unit arrives at 1245 S.
First St., Brooklyn, WI 12345 at 0228 and is met by a 22-year-old white female. She has been
stabbed in the leg and is bleeding from the wound. Further examination reveals burns on one
arm. A first responder stops the bleeding, bandages the wound, and provides care for the burns.
The patient’s family chooses to provide transportation to the closest hospital for further treat-
ment. She is transferred at 0256 hours. The incident number is 0001234.
6-12
6-13
EXERCISE SCENARIO 6.1: Unconscious Person

Directions: Read the call information in the exercise below. Use the information provided to complete the EMS Module form.
Compare your work to the answers provided on the completed EMS Module form. If your answers are different from the ones
provided, read over the EMS Module again.
A fire department first-responder unit, TR 100, Station 001, is dispatched at 1405 hours on April
1, 1997 to a medical call – incident #9704567. The unit is staffed with a driver, an officer, and an
EMT. They arrive at 210 W. Main Street, Minlo, WI 12345 at 1407 hours and reach the patient’s
side at 1410. They find a 22-year-old white male unconscious on the floor. His friends tell them
that he just shot up on heroin and has overdosed. The patient shows signs of shallow breathing,
pin-point pupils, and has a faint pulse. The EMT inserts an airway, administers oxygen, and assists
in ventilation.
A private medic unit arrives and the Paramedic administers a dose of Narcan. The patient responds
and begins breathing on his own. At 1440, the Paramedic determines that the patient has stabi-
lized and arranges transport to an emergency room for further evaluation.
6-14
Delete
A Incident Date Change EMS

Check if same date
as Alarm date


None
1 White
Check all applicable boxes If an illness, not an
OR 5 Native Hawaiian, Other 2 Unconscious go to H3
3
Month Day Year U Undetermined 4 Possibly impaired by drug 1 Accidental
Gender Ethnicity 6 Physically disabled 3 Inflicted, not self
E2 F2 1 7 Physically restrained
Hispanic or Latino
1 Male 2 Female 2 Non Hispanic or Latino 8 Unattended person
Body Site of Injury Injury Type Cause of

H1 List up to five body sites
H3 Illness/Injury

J None K
Burn care 18 1 Witnessed?
05 Oxygen therapy 2 Child safety seat
Airbag
U Undetermined

L1 Initial Level of
None M N
EMS Not transported
1 Improved
First Responder
EMT-B (Basic)
EMT-P (Paramedic) 1
0 Other provider 2
6-15
6-16
EXERCISE SCENARIO 6-2: MVA on I-95

Directions: Read the call information in the exercise below. Use the information provided to complete the entire EMS Module
form and other required forms. Compare your work to the answers provided in Appendix A. If your answers are different from
the ones provided, read over the EMS Module again.
The Alberta Fire Department (FDID #92188) received a call for an MVA on I-95 near mile
marker 73 and Exit 2B in Brunswick, Virginia, 23351 on May 3, 2005. The dispatcher assigned the
incident (#5455) to Engine Co. 2 and Truck 1 from Shift C. The units received the alarm at 11:58
p.m. and arrived at the scene in six minutes with 4 firefighters on each unit. The owner of the
vehicle, Mr. Robert L. Anderson, was driving to Emporia, Virginia, to return his son, Joseph, to his
mother. Mr. Anderson lives at 1630 Second Avenue, Jarrett, North Carolina, 24501. His telephone
number is 555-432-0987. He said that he was driving for 2 hours and became drowsy from a
prescription drug that he took; he lost control of the car and it crashed into the guardrail. He
called 9-1-1 from his cellular telephone. The vehicle was a 1999 Ford Explorer, Virginia License
Plate Number ACZ586, and VIN 1FBEU54X3ABC45634. Mr. Anderson, a 49-year-old black male,
was bleeding from the head. He cut his head when his car hit the guardrail. He was not wear-
ing a safety belt and the airbag in the vehicle did not inflate. Firefighter Steve Cooke, EMT-Basic,
approached Officer Morrison at 12:06 a.m. Firefighter Cooke stopped the bleeding. No other
treatment was needed. Mr. Anderson’s overall status improved. The towing service provider gave
Mr. Anderson a ride from the incident. The last unit cleared the scene at 12:35 a.m. FF1 Steve B.
LaCivita, Badge No. 230, completed the report after returning to Station No. 1. Captain Ernest
Greene, Badge No. 100, was the officer in charge. The incident was in Census Tract 501.2, District
A05. The Virginia Department of Transportation, 23 Washington Street NE, Richmond, VA 23219,
manages Virginia highways.
6-17
MM DD YYYY
A Delete
Change
NFIRS–1
Basic
No Activity
Location Type Check this box to indicate that the address for this incident is provided on the Wildland Fire Census Tract
B Module in Section B, “Alternative Location Specification." Use only for wildland fires.
-
Street address
Intersection
In front of Number/Milepost Prefix Street or Highway Street Type Suffix
Rear of -
Adjacent to Apt./Suite/Room City State ZIP Code
Directions
US National Grid Cross Street, Directions or National Grid, as applicable
Incident Type Dates and Times Midnight is 0000 Shifts and Alarms
C E1 E2 Local Option
Month Day Year Hour Min
Incident Type Check boxes if ALARM always required
dates are the
Alarm Shift or Alarms District
Aid Given or Received same as Alarm
D None
Date. Platoon
ARRIVAL required, unless canceled or did not arrive
1 Special Studies
2
Mutual aid received
Auto. aid received
Arrival E3 Local Option
Their FDID Their CONTROLLED optional, except for wildland fires
3 Mutual aid given State
4 Auto. aid given Controlled
Special Special
5 Other aid given Last Unit LAST UNIT CLEARED, required except for wildland fires Study ID# Study Value
Their Incident Number
Cleared
Actions Taken Resources Estimated Dollar Losses and Values

F G1 G2
Check this box and skip this block if an Required for all fires if known.
Apparatus or Personnel Module is used. LOSSES: Optional for non-fires. None
Primary Action Taken (1) Property $ , ,
Apparatus Personnel
Suppression Contents $ , ,
Additional Action Taken (2)
EMS PRE-INCIDENT VALUE: Optional
Other Property $ , ,
Additional Action Taken (3)
Check box if resource counts include aid Contents $ , ,
received resources.
Completed Modules Casualties H3 Hazardous Materials Release None I Mixed Use

Fire–2
H1 None
Property
Not mixed
Structure Fire–3
Deaths Injuries 10 Assembly use
Fire 1 Natural gas: slow leak, no evacuation or HazMat actions
20 Education use
Civilian Fire Cas.–4 Service 2 Propane gas: <21-lb tank (as in home BBQ grill) 33 Medical use
Fire Service Cas.–5 3 Gasoline: vehicle fuel tank or portable container 40 Residential use
Civilian 4 51 Row of stores
EMS–6 Kerosene: fuel burning equipment or portable storage
5 53 Enclosed mall
HazMat–7 Detector Diesel fuel/fuel oil: vehicle fuel tank or portable storage
Wildland Fire–8
H2 Required for confined fires.
6 Household solvents: home/office spill, cleanup only
58
59
Business & residential
Office use
7 Motor oil: from engine or portable container 60 Industrial use
Apparatus–9 1 Detector alerted occupants 8 Paint: from paint cans totaling <55 gallons 63 Military use
Personnel–10 2 Detector did not alert them 0 65 Farm use
Other: special HazMat actions required or spill > 55 gal
Arson–11 U Unknown 00 Other mixed use
(Please complete the HazMat form.)
Property Use 341 Clinic, clinic-type infirmary 539 Household goods, sales, repairs
J Structures
None
342 Doctor/dentist office 571 Gas or service station
131 Church, place of worship 361 Prison or jail, not juvenile 579 Motor vehicle/boat sales/repairs
161 Restaurant or cafeteria 419 1- or 2-family dwelling 599 Business office
162 Bar/tavern or nightclub 429 Multifamily dwelling 615 Electric-generating plant
213 Elementary school, kindergarten 439 Rooming/boarding house 629 Laboratory/science laboratory
215 High school, junior high 449 Commercial hotel or motel 700 Manufacturing plant
241 College, adult education 459 Residential, board and care 819 Livestock/poultry storage (barn)
311 Nursing home 464 Dormitory/barracks 882 Non-residential parking garage
331 Hospital 519 Food and beverage sales 891 Warehouse
Outside 936 Vacant lot 981 Construction site
124 Playground or park 938 Graded/cared for plot of land 984 Industrial plant yard
655 Crops or orchard 946 Lake, river, stream
Look up and enter a
669 Forest (timberland) 951 Railroad right-of-way Property Use code and Property Use
807 Outdoor storage area 960 Other street description only if you Code
have NOT checked a
919 Dump or sanitary landfill 961 Highway/divided highway Property Use box.
Open land or field Property Use Description
931 962 Residential street/driveway
6-18
Person/Entity Involved
K1 Local Option
Business Name (if applicable) Area Code Phone Number
Check this box if same

address as incident
Mr., Ms., Mrs. First Name MI Last Name Suffix
Location (Section B).
Then skip the three
duplicate address
lines. Number Prefix Street or Highway Street Type Suffix
Post Office Box Apt./Suite/Room City
State ZIP Code

More people involved? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
Same as person involved?

Owner
K2 Then check this box and skip
the rest of this block.
Local Option Business Name (if applicable) Area Code Phone Number
Check this box if same

address as incident
Location (Section B). Mr., Ms., Mrs. First Name MI Last Name Suffix
Then skip the three
duplicate address
lines.
Number Prefix Street or Highway Street Type Suffix
Post Office Box Apt./Suite/Room City
State ZIP Code
Remarks:
L
Local Option
Fire Module Required?

Check the box that applies and then complete the Fire Module
based on Incident Type, as follows:
Buildings 111 Complete Fire & Structure Modules

Special structure 112 Complete Fire Module &
Section I, Structure Module
Confined 113–118 Basic Module Only
Mobile property 120–123 Complete Fire Module
Vehicle 130–138 Complete Fire Module
Vegetation 140–143 Complete Fire or Wildland Module
Outside rubbish fire 150–155 Basic Module Only
Special outside fire 160 Complete Fire or Wildland Module
Special outside fire 161–163 Complete Fire Module
Crop fire 170–173 Complete Fire or Wildland Module
ITEMS WITH A MUST ALWAYS BE COMPLETED!
More remarks? Check this box and attach Supplemental Forms (NFIRS–1S) as necessary.
Authorization
M
Check box if Officer in charge ID Signature Position or rank Assignment Month Day Year
same as
Officer in
charge.
Member making report ID Signature Position or rank Assignment Month Day Year
6-19
NFIRS–2
A MM DD YYYY Delete
Fire
FDID Incident Date Station Incident Number Change
State Exposure
Property Details On-Site Materials Complete if there were any significant amounts of
B C or Products None
commercial, industrial, energy, or agricultural products or
or materials on the property, whether or not they became involved
Enter up to three codes. Check one box for each code On-Site Materials
Storage Use
B1 Not Residential
Estimated number of residential living units in
entered.
1 Bulk storage or warehousing
building of origin whether or not all units 2 Processing or manufacturing
3 Packaged goods for sale
became involved 4 Repair or service
On-site material (1) U Undetermined
B2 Number of buildings involved

Buildings not involved 1
2
Bulk storage or warehousing
Processing or manufacturing
4 Repair or service
On-site material (2) U Undetermined
None
B3 ,
Acres burned (outside fires) Less than one acre
1
2
Bulk storage or warehousing
Processing or manufacturing
On-site material (3)
4 Repair or service
U Undetermined
Ignition Cause of Ignition Human Factors

D E1 Check box if this is an exposure report.
Skip to E3 Contributing to Ignition
Section G
D1 1 Intentional None
Area of fire origin 2 Unintentional 1 Asleep
3 Failure of equipment or heat source 2 Possibly impaired by
4 Act of nature alcohol or drugs
D2 Heat source 5 Cause under investigation 3 Unattended person
U Cause undetermined after investigation 4 Possibly mentally disabled
5 Physically disabled
D3 E2
Factors Contributing to Ignition None
6 Multiple persons involved
Item first ignited Check box if fire spread was
1 confined to object of origin.
7 Age was a factor
D4 Factor contributing to ignition (1) Estimated age of

person involved
Type of material first ignited Required only if item first
ignited code is 00 or <70
Factor contributing to ignition (2) 1 Male 2 Female
Equipment Involved in Ignition Equipment Power Source Fire Suppression Factors None
F1 F2 G
Enter up to three codes.
None If equipment was not involved, skip to
Section G
Equipment Power Source
Fire suppression factor (1)

Equipment Involved Equipment Portability
Brand
F3
1 Portable
Model Fire suppression factor (2)
2 Stationary
Serial #
Portable equipment normally can be moved by
one or two persons, is designed to be used in
Year multiple locations, and requires no tools to install. Fire suppression factor (3)
Mobile Property Involved None Mobile Property Type and Make Local Use
H1 H2
Pre-Fire Plan Available
Not involved in ignition, but burned Some of the information presented in this report may be
1
based upon reports from other agencies:
Mobile property type
2 Involved in ignition, but did not burn
3 Involved in ignition and burned
Arson report attached
Mobile property make Police report attached
Coroner report attached
Mobile property model Year Other reports attached
License Plate Number State VIN
Structure fire? Please be sure to complete the Structure Fire form (NFIRS–3).
6-20
Delete
A Change EMS

Check if same date
as Alarm date


None
1 White
Check all applicable boxes If an illness, not an
OR 5 Native Hawaiian, Other 2 Unconscious go to H3
3
Month Day Year U Undetermined 4 Possibly impaired by drug 1 Accidental
Gender Ethnicity 6 Physically disabled 3 Inflicted, not self
E2 F2 1 7 Physically restrained
Hispanic or Latino
1 Male 2 Female 2 Non Hispanic or Latino 8 Unattended person
Body Site of Injury Injury Type Cause of

H1 List up to five body sites
H3 Illness/Injury

J None K
Burn care 18 1 Witnessed?
05 Oxygen therapy 2 Child safety seat
Airbag
U Undetermined

L1 Initial Level of
None M N
EMS Not transported
1 Improved
First Responder
EMT-B (Basic)
EMT-P (Paramedic) 1
0 Other provider 2
6-21

Nfirs Module 6 Ems

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Nfirs Module 6 Ems

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NFIRS 5.

Pretest #6 - Emergency Medical Services (EMS) Module

2. EMS-type activities are a significant portion of a fire department’s operational workload.

3. The EMS Module is a required NFIRS Module.

Using the EMS Module

Section A: FDID, State, Incident Number, Incident

Month Day Year Hour/Min

Age or Date of Birth Race Human Factors None Other

FDID State Incident Date Station Incident Number Exposure

D Provider Impression/Assessment Check one box only None/no patien

7 Cardiac dysrhythmia 25 Hypothermia 33 Seizure

Section E: Age or Date of Birth, Gender 15

Number of Patients Patient Number Date/Time NFIRS 5.0 Self-StudyMonth

17 Cardiac dysrhythmia 25 Hypothermia 33 Seizure

Age or Date of Birth Race Human Factors None Other

24 Hyperthermia injury-reduction programs based on human factors.

and Cause of Injury/Illness

02 Anti-shock trousers 15 Intubation (ET) Used or deployed by patient.

Race You can record up toFactors

Injury Type Cause of

Enter a code in Block

Block H1 Block H2 Block H3

Body Site of Injury YearInjury Type Cause

10 Abdominal pain 18 Chest pain Section I: Procedures Used

Section J: Safety Equipment

10 Abdominal pain 18 Chest pain 26 Hypovolemia 34

Section K: Cardiac Arrest

Intubation (ET) Used or deployed by patient.

Highest Level of Care Provided on Scene 11

Highest Level of Care

Highest Level of Care Patient Status

Section M: Patient Status

Initial Level of Highest Level of Care None M

Highest Level of Care Patient Status

EXAMPLE: Injured Person

EXERCISE SCENARIO 6.1: Unconscious Person

Month Day Year Hour/Min

10 Abdominal pain 18 Chest pain 26 Hypovolemia 34 Sexual assault

Age or Date of Birth Race Human Factors None Other

Body Site of Injury Injury Type Cause of

Procedures Used Safety Cardiac Arrest

Highest Level of Care Patient Status

EXERCISE SCENARIO 6-2: MVA on I-95

Actions Taken Resources Estimated Dollar Losses and Values

Completed Modules Casualties H3 Hazardous Materials Release None I Mixed Use

Check this box if same

Post Office Box Apt./Suite/Room City

State ZIP Code

Same as person involved?

Check this box if same

Post Office Box Apt./Suite/Room City

State ZIP Code

Fire Module Required?

Buildings 111 Complete Fire & Structure Modules

B2 Number of buildings involved

Ignition Cause of Ignition Human Factors

D4 Factor contributing to ignition (1) Estimated age of

Fire suppression factor (1)

License Plate Number State VIN

Month Day Year Hour/Min

10 Abdominal pain 18 Chest pain 26 Hypovolemia 34 Sexual assault

Age or Date of Birth Race Human Factors None Other

Body Site of Injury Injury Type Cause of

Procedures Used Safety Cardiac Arrest