PORTABLE/WHEELED UNIT FIRE EXTINGUISHER INCIDENT REPORT

1. Indicate the type of extinguisher used:   ABC Dry Chem   BC Dry Chem   CO2   Purple K   Class D   Clean Agent   Pressurized Water   K Class   Water Mist   Loaded Stream   AFFF   FFFP 2. Indicate the capacity of the extinguisher used:   Please choose below 2-5 lbs. 6-10 lbs. 11-15 lbs. 16-20 lbs. 21-30 lbs >30 lbs 1.5 gal. 1.8 gal. 2.5 gal. 6 liter 33 gal. 3. Classification of fire:   Class A   Class B   Class C   Class D   Class K 4. Type of Occupancy:   Assembly   Education   Day Care   Health Care   Detention/Correction   Residential   Lodging   Residential Board & Care   Mercantile   Business   Industrial   Storage   Vehicle   Other 5. If other, please explain:   6. Did the extinguisher extinguish the fire?   Yes   No 7. If no, how was the fire extinguished?   Sprinkler System   Other Suppression System   Fire Department   Occupant Use Hose   Self-Extinguished   Other 8. If other, please explain:   9. If extinguisher failed to extinguish fire, why?   Fire too large   Operator error   Operator not trained   Extinguisher not full   Extinguisher not pressurized   Wrong type of Extinguisher   Extinguisher Malfunction (see below)   Unknown   Other 10. If other, please explain:   11. Reason for malfunction:   No maintenance   Improper recharge   Valve failed to open   Unknown   Other 12. If other, please explain:   13. Was the Fire Department called?   Yes   No 14. If yes, was the Fire Department needed?   Yes   No 15. Was the facility equipped with a sprinkler system?   Yes   No 16. If yes, did the sprinkler system operate properly?   Yes   No 17. Please enter your company name and location.   18. Date of report:   19. Date of incident: