Please fill out this form within 48 hours of the termination of the incident.

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* 1. Date:

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* 2. Time dispatched:

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* 3. Time on scene:

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* 4. Time departed:

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* 5. Type of incident:

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* 6. CART members responding:

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* 7. Incident commander on scene:

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* 8. Fire investigator on scene:

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* 9. Address of scene:

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* 10. Number of individuals needing assistance:

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* 11. Number of residents displaced:

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* 12. Number of pets displaced:

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* 13. Property manager/homeowner name:

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* 14. Property manager/homeowner phone:

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* 15. Resident #1 information:

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* 16. Resident #2 information:

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* 17. Resident #3 information:

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* 18. Resident #4 information:

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* 19. Resident #5 information:

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* 20. Resident #6 information:

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* 21. Resources used at scene:

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* 22. Resources used at scene:

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* 23. Resources used at scene:

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* 24. Resources used at scene:

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* 25. Resources used at scene:

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* 26. Residents in need of a hotel:

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* 27. Was CIRT notified?

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* 28. Was Red Cross notified?

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* 29. Name(s) of Red Cross volunteer(s):

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* 30. Narrative of incident:

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* 31. To the best of my knowledge and recollection, I have accounted for the incident to which I responded as a CART member.

A copy of this report will be filed as a permanent CART record as well as copies forwarded to:

The fire inspector in charge of the incident and the incident commander on duty during incident

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