Smoking on Oxygen Incident Survey

The NH State Fire Marshal's Office is engaged in a public education campaign to demonstrate the hazards of smoking while on home oxygen systems. We need your help. Please help us by filling out this survey. If you have not had any fires in the past five calendar years (Jan 1, 2007 through December 31, 2011), please simply answer no on the first question and submit the survey. If you have had any incidents, please fill out the remaining questions for each incident that you had in your community.

Thank you for your assistance.
Rob Farley
Deputy State Fire Marshal

* 1. Please enter your Department name

* 2. Enter the name of your town?

* 3. In the past five calendar years (2007 through 2011), has your department responded to any fire incidents or burn injuries involving patients smoking on oxygen?

* 4. If yes, please continue to the following questions for each incident in your community.
Please submit a separate entry for each incident during the survey period.
Did this incident result in personal injury?

* 5. What was the severity of the injury?

* 6. Were NHFIRS reports filed for each incident?

* 7. If answer to Question #4 is yes, please provide NHFIRS incident number for the incident?

* 8. What was the date of the incident?