North Carolina Response Rating System
Pre Survey Package
Community Risk
Communication
Fire Department
Water Supply
Rating Inspection Check Sheet
This sheet is to assist the fire department tracking the progress of completing the field worksheets
Completed
Task
Contact information completed with phone numbers and email address
Fire station(s) location information completed
Map of district with station locations, hydrants and static water points
Tax ID number
Charter and amendments if this applies
Documentation the dept. is part of municipal government, if applies this
All current contracts for fire protection
Current Automatic Aid Agreements, if this applies
Confirmation of Current Workman’s Comp insurance coverage
Most current approved map including approval documentation
Population, Square Miles and Total Alarms
Turnout Gear inventory
Pager and Radio information
12 pervious months of maint. and equip. check sheets for 1st out apparatus
Three most recent years of Pump Test
Three most recent years of Hose Test
Most Current Weight Tickets
Apparatus and Equipment Sheets completed for all fire apparatus
Three most recent years of Aerial Testing
Three most recent years of hydrant and water point inspections
Hydrant Flow tests conducted within the last 5 years
Apparatus Response Procedures or Response Plans
Structure fire response sheet completed
Automatic Aid response sheet completed
Staffing sheet completed
Training information, including EXHIBIT 3 completed
Pre-Plans for review
Standard Operation Procedures/Guidelines
Automatic Aid sheets completed
Water supply forms completed
Alternate water supply information completed, if this applies
Static water point form completed, if this applies
Community Risk forms completed
Page
1,2,3
4,5
4,5
7
7
7
7
7
7
7
8
8
8
9
9
9
9
Exhibit 2
9
9
9
10
11
12
13
14
Exhibit 3
14
14
15
Exhibit 4
17
19,20
Exhibit 5
21-24
Responsible Person
North Carolina Response Rating Schedule
Inspection Worksheets
Date of Inspection _______________________________________
Fire District Name _______________________________________
Department Name _______________________________________
Mailing Address
_______________________________________
County (s) served
_______________________________________
Department Phone _______________________________________
Department Fax
_______________________________________
1
Rating Inspection Work Sheet
Contacts
Fire Chief
Name
Title
Organization
Address
City
________________________
Phone Work ________________________
________________________
Phone Mobile ________________________
________________________
Fax
________________________
________________________
E-mail
________________________
________________________ State____ Zip ____________
Board President
Name
________________________
Phone Work ________________________
Title
________________________
Phone Mobile ________________________
Organization ________________________
Fax
________________________
Address
________________________
E-mail
________________________
City
________________________ State____ Zip ____________
Fire Marshal (Complete an entry for each jurisdiction served by the department)
Name
________________________
Phone Work ________________________
Phone Mobile ________________________
Title
________________________
Organization ________________________
Fax
________________________
Address
________________________
E-mail
________________________
City
________________________ State____ Zip ____________
Fire Marshal (Complete an entry for each jurisdiction served by the department)
Name
________________________
Phone Work ________________________
Title
________________________
Phone Mobile ________________________
Organization ________________________
Fax
________________________
Address
________________________
E-mail
________________________
City
________________________ State____ Zip ____________
Mapping or GIS Contact
Name
________________________
Phone Work ________________________
Title
________________________
Phone Mobile ________________________
Organization ________________________
Fax
________________________
Address
________________________
E-mail
________________________
City
________________________ State____ Zip ____________
2
Rating Inspection Work Sheet
Contacts
County Manager (Complete an entry for each jurisdiction served by the department)
Name
________________________
Phone Work ________________________
Phone Mobile ________________________
Title
________________________
Organization ________________________
Fax
________________________
Address
________________________
E-mail
________________________
City
________________________ State____ Zip ____________
County Manager (Complete an entry for each jurisdiction served by the department)
Name
________________________
Phone Work ________________________
Title
________________________
Phone Mobile ________________________
Organization ________________________
Fax
________________________
Address
________________________
E-mail
________________________
City
________________________ State____ Zip ____________
City Manager or Mayor (Complete an entry for each jurisdiction served by the department)
Name
________________________
Phone Work ________________________
Title
________________________
Phone Mobile ________________________
Organization ________________________
Fax
________________________
Address
________________________
E-mail
________________________
City
________________________ State____ Zip ____________
City Manager or Mayor (Complete an entry for each jurisdiction served by the department)
Name
________________________
Phone Work ________________________
Title
________________________
Phone Mobile ________________________
Organization ________________________
Fax
________________________
Address
________________________
E-mail
________________________
City
________________________ State____ Zip ____________
Other Contact
Name
________________________
Phone Work ________________________
Title
________________________
Phone Mobile ________________________
Organization ________________________
Fax
________________________
Address
________________________
E-mail
________________________
City
________________________ State____ Zip ____________
3
Rating Inspection Work Sheet
Fire Station Locations
Physical Address
Station 1: __________________________
__________________________
__________________________
Station Size
_____________
Heated: Yes
Department Personnel:
On Duty
No
Heated: Yes
Department Personnel:
On Duty
Heated: Yes
Department Personnel:
On Duty
On Call
No
Combination
Latitude ____________ N Longitude ____________ W
No
Emergency Power: Yes
No
If yes, documentation of the testing should be available for review
On Call
Physical Address
Station 4: __________________________
__________________________
__________________________
_____________
Emergency Power: Yes
If yes, documentation of the testing should be available for review
Year Constructed ________ Type of Construction______________
Number of Bays ____
Station Size
Combination
Latitude ____________ N Longitude ____________ W
No
Physical Address
Station 3: __________________________
__________________________
__________________________
_____________
No
Year Constructed ________ Type of Construction______________
Number of Bays ____
Station Size
Emergency Power: Yes
If yes, documentation of the testing should be available for review
On Call
Physical Address
Station 2: __________________________
__________________________
__________________________
_____________
Use WGS 84 Coordinates, decimal degrees
Example 35.56738 N
- 79.6532 W
Year Constructed ________ Type of Construction______________
Number of Bays ____
Station Size
Latitude ____________ N Longitude ____________ W
Combination
Latitude ____________ N Longitude ____________ W
Year Constructed ________ Type of Construction______________
Number of Bays ____
Heated: Yes
Department Personnel:
On Duty
No
Emergency Power: Yes
No
If yes, documentation of the testing should be available for review
On Call
Combination
4
Rating Inspection Work Sheet
Fire Station Locations
Physical Address
Station 5: __________________________
__________________________
__________________________
Station Size
_____________
Year Constructed ________ Type of Construction______________
Number of Bays ____
Heated: Yes
Department Personnel:
On Duty
No
_____________
Heated: Yes
Department Personnel:
On Duty
Heated: Yes
Department Personnel:
On Duty
On Call
No
Combination
Latitude ____________ N Longitude ____________ W
No
Emergency Power: Yes
No
If yes, documentation of the testing should be available for review
On Call
Physical Address
Station 8: __________________________
__________________________
__________________________
_____________
Emergency Power: Yes
If yes, documentation of the testing should be available for review
Year Constructed ________ Type of Construction______________
Number of Bays ____
Station Size
Combination
Latitude ____________ N Longitude ____________ W
No
Physical Address
Station 7: __________________________
__________________________
__________________________
_____________
No
Year Constructed ________ Type of Construction______________
Number of Bays ____
Station Size
Emergency Power: Yes
If yes, documentation of the testing should be available for review
On Call
Physical Address
Station 6: __________________________
__________________________
__________________________
Station Size
Latitude ____________ N Longitude ____________ W
Combination
Latitude ____________ N Longitude ____________ W
Year Constructed ________ Type of Construction______________
Number of Bays ____
Heated: Yes
Department Personnel:
On Duty
No
Emergency Power: Yes
No
If yes, documentation of the testing should be available for review
On Call
Combination
If a department should have more than 8 station complete Exhibit 1
5
Rating Inspection Work Sheet
Mapping
The departments will be required to provide a computer generated map with the following information.
•
•
•
•
•
•
•
•
•
Maps must be labeled with the appropriate Fire District name
Maps must have a scale printed on the map, with 1” = 1,200’ the preferred scale,
The fire station physical location(s),
Road base with road names,
All pressure hydrants plotted
All static water points plotted and identified with ID number
Maps must include the Response District boundary of the Department
Maps must include the five-mile insurance district boundary line
Maps must include the total road miles located within the five-mile district, with no overlapping of
roadways between this station and any other station or Fire District. Do not include interstate
highways when calculating total road miles. Round all mileages to the nearest tenth mile.
The following information is needed if the GIS Department has the software capable of producing this data.
•
•
•
Total road miles within 1-1/2 miles of each station, within the five-mile district and with no
overlapping of roadways between this station and any other station or Fire District. Round all mileages
to the nearest tenth mile.
Total road miles within 2-1/2 miles of each station, within the five-mile district and with no
overlapping of roadways between this station and any other station or Fire District. Round all mileages
to the nearest tenth mile.
We would request the GIS department provide SHAPE FILES for the fire district. The file should
include Station Locations, Approved response district boundary line, 5-mile fire district line, hydrant
layer and static water point layer.
The inspector will be glad to talk with the GIS person if they should have any questions concerning the
mapping requirements.
6
Rating Inspection Work Sheet
Governmental Information
Services Provided:
Fire
Rescue
EMS
First Responder
The following items must be available for review at the time of the inspection
____
Fire Department Tax ID Number or FEIN Number: _______________________________
____
Charter and Amendments for the rural fire protection district (s)
Date of Original Charter:
Date (s) of Charter Amendments:
____________
____________ ____________ ____________ ____________
(If applicable)
____
Municipal departments must provide documentation that the department is part of the Municipal
Government
____
All contracts in place for fire protection services rendered, complete, signed and dated
____
All Automatic Aid Contracts in place for fire protection services
____
Confirmation of Workman's Compensation Insurance currently enforced
____
General Fund ___
District Funding and Tax Rate
Service District ___ Rural Fire Protection District ___
Tax Rate______
County Contracts and County Maps
Current GIS Map
County
- or – Current NC DOT Map and Written Description
Map Approval Date
Date of Contract
AutAutomatic Aid
Yes
No
Yes
No
Yes
No
Yes
No
Municipal Contracts
Town or City in which the district provides protection
City or Town
Date of Contract
7
General Fire Department Information
Demographics
If a Rural District contains a Municipality within its boundary and the districts are graded by different Methods (ex: Method 3 for a Rural District
& a Method 1 for a Municipal District), complete the Demographic information for both Districts, otherwise just complete for the Rural District
Population of Rural District
______
Population of Municipality City or Town
______
Square Miles of Rural District
______
Square Miles of Municipality City or Town
______
Total Road Miles in the Municipality
______
Total Road Miles in 5 Five Mile Rural District ______
Road Miles with 1 ½ Miles of
Station 1 ______
Road Miles with 2 ½ Miles of
Station 1 ______
Number of 3 Story Buildings
Station 1 ______
Station 2 ______
Station 2 ______
Station 2 ______
Station 3 ______
Station 3 ______
Station 3 ______
Station 4 ______
Station 4 ______
Station 4 ______
Station 5 ______
Station 5 ______
Station 5 ______
Station 6______
Station 6 ______
Station 6 ______
Station 7 ______
Station 7 ______
Station 7 ______
Station 8 ______
Station 8 ______
Station 8 ______
Alarms
Total Number of all Alarms ______
Year ______
Communications
Number of Pagers ______
Number of Portable Radios ______ Number of Mobile Radios ______
Method(s) of Alarm Receipt for Members Responding
Radio Pagers ___
Printer / Fax ___
Station Radios ___
Voice Amplification ___
Telephone
Siren, Other Outside Warning Device
___
___
Protective Clothing
Total # Coats:
________
Total # Bunker Pants: ________
Total # Helmets:
________
Total # Pr. Gloves:
________
Total # Pr. Boots:
________
Total # Hoods:
________
8
Rating Inspection Work Sheet
Apparatus and Equipment
The information below will be reviewed during the inspection.
_____ Maintenance & Equipment Check Sheets - The department shall provide the previous 12 months of
apparatus maintenance and equipment check off sheets for the first out Engine and Tanker.
The check sheets will be reviewed by the inspector at the time of the inspection, copies are not
needed
_____ Pump Test – The pump test must be complete accurate and have been conducted within 12 months
prior to the fire department inspection. The test should be run the full 40 minutes, form filled out and
signed.
The last 3 years of pump test records will be reviewed by the inspector at the time of the inspection,
copies are not needed
Frequency of Test:
1 Year ____
2 Year ____
3 Year ____
4 Year ____
5 Years or Greater ____
_____ Hose Test – The inspector will review the 3 most recent hose tests.
The last 3 years of hose test records will be reviewed by the inspector at the time of the inspection,
copies are not needed
Frequency of Test:
1 Year ____
2 Year ____
3 Year ____
4 Year ____
5 Years or Greater ____
_____ Weight Tickets – Weight tickets from a certified scale showing the gross (full) weight of the firefighting
apparatus are required. Apparatus must have been weighed within the last 12 months of the
inspection. Weight tickets must be stamped and signed by the weight master.
The weight tickets will be reviewed by the inspector at the time of the inspection, copies are not
needed
_____ GVW Plate: The apparatus shall be equipped with a GVW (gross vehicle weight) plate from the
manufacturer attached to the vehicle or official verification of the apparatus GVW.
_____ Equipment and Hose: The inspector will verify the equipment on board the firefighting apparatus using
Exhibit # 2
_____ Aerial Ladder or Elevating Platform Test: The inspector will review the 3 most recent aerial ladder
tests. They will also be reviewing the most current Non-Destructive test for the apparatus.
The inspector will not need copies of the aerial/ladder tests. Ground ladder test will not be reviewed.
Frequency of Test:
1 Year ____
2 Year ____
3 Year ____
4 Year ____
5 Years or Greater ____
_____ Inspection and Fire Flow Testing of Hydrants: The department shall provide the last 3 years of hydrant
inspections and flow test records for the inspector to review. This will include all static water points if
applicable.
The inspector will not need copies of these records.
Frequency of Test:
1 Year ____
2 Year ____
3 Year ____
4 Year ____
5 Years or Greater ____
Exhibit 2, Apparatus Sheet must be completed for each apparatus
9
Rating Inspection Work Sheet
Apparatus Response Procedures
Response
Combination
Considered
Zone 1
Residential Fire Alarm
Commercial Fire Alarm
Residential Structure Fire
Commercial Structure Fire
Zone 2
Residential Fire Alarm
Commercial Fire Alarm
Residential Structure Fire
Commercial Structure Fire
Zone 3
Residential Fire Alarm
Commercial Fire Alarm
Residential Structure Fire
Commercial Structure Fire
Zone 4
Residential Fire Alarm
Commercial Fire Alarm
Residential Structure Fire
Commercial Structure Fire
Zone 5
Residential Fire Alarm
Commercial Fire Alarm
Residential Structure Fire
Commercial Structure Fire
Zone 6
Residential Fire Alarm
Commercial Fire Alarm
Residential Structure Fire
Commercial Structure Fire
Apparatus
Unit Numbers
If your department has only 1 station and responds to all calls in a like manner, complete data for ZONE 1 only.
If your department has only 1 station but responds in a different manner to various areas (ex: Hydranted area
vs. Non-Hydranted area, etc.), complete the data for each Zone needed to describe your responses needs.
If your department has multiple stations and responds in a different manner to multiple areas (ex: Ladder Co.
to some portions & a Service Co. to others, etc.), complete the data for each Zone needed to describe your
various response needs.
10
Rating Inspection Work Sheet
Structure Fire Response:
Start by listing each of your fire apparatus below unit #. Then record your structure fire responses that took place in the last 12 months or the last 20 structure
fires, we must have at least 5 structure fire listed if you have to go back further than 12 months. List the number of responding firefighting personnel and place
an “x” below all the apparatus that responded on first alarm. Your list should only include your department’s structure fire calls in your district and not
automatic or mutual aid calls to other districts. Do not include personnel who stand by or wait at the station until needed. DO NOT INCULDE AUTOMATIC AID
RESPONSE ON THIS FORM
#
Date
00/00/00
Time
24 hr.
Format
Number of
Firefighters
On-Duty
at the
station
Number of
Firefighters
On-Call
When listing your apparatus list all the engines first, then ladders or service trucks. Tankers should
be listed last
Unit #
Unit #
Unit #
Unit #
Unit #
Unit #
Unit #
Unit #
Unit #
Unit #
Unit #
Unit #
Unit #
Unit #
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
11
Unit #
Rating Inspection Work Sheet
Automatic Aid Fire Response:
#
Date
00/00/00
Time
24 hr.
Format
List each Automatic Aid Fire Departments that responded on first alarm that is within 5 miles of your district line. List the number of
responding firefighting personnel, indicate if personnel were on duty or on call. Do not include any personnel who was on standby at the
station only personnel that responded should be listed on this from.
Auto Aid Dept
Units
On
Call
Auto Aid Dept
On
Duty
Units
On
Call
Auto Aid Dept
On
Duty
Units
On
Call
Auto Aid Dept
On
Duty
Units
On
Call
Auto Aid Dept
On
Duty
Units
On
Call
Auto Aid Dept
On
Duty
Units
On
Call
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
12
On
Duty
Department Membership and Staffing
Roster of department members: List all Officers, Drivers, Firefighters
Fire Force
Members
Fire Force
Members
Chief
Sergeants
Dep. Or Asst. Chief
Drivers
Battalion Chief
Firefighters
Captains
Chief Aids
Lieutenants
Non-Fire Force
0
Total Member
ON DUTY COMPANY PERSONNEL
On- Duty Strength
Day(s)
Time Span
Hours on Duty
per Firefighter
0
0
0
0
0
0
0
0
0
0
X
X
X
X
X
X
X
X
X
X
X
Firefighters on
Duty
0
0
0
0
0
0
0
0
0
0
TOTAL
Divided by 168 (hours in a week)
Average on Duty
Deduct the following and show calculations
Vacation Time
Sick Time
Other Time Off
On Duty Response
X
X
X
X
X
X
X
X
X
X
X
Days on
Duty
=
Total Hours
0
=
0
0
=
0
0
=
0
0
=
0
0
=
0
0
=
0
0
=
0
0
=
0
0
=
0
0
=
0
=
0.00
168
0.00
=
Does the department have a minimum staffing policy: Yes ____ No _____
If yes, the department shall provide a copy for review at the time of the
inspection If yes, what is the minimum staffing level :_______________
13
Rating Inspection Work Sheet
Training
For credit in the area of training the department must be able to provide documentation of the training and
certification for each firefighter.
Facilities
Burn Building
Yes ___
No ___
Drill Tower
Yes ___
No ___
If yes how many stories
____
Training Area
Yes ___
No ___
If yes how many acres
____
If the department does not have a Training Facilities but the firefighters have trained at a facility in the last 12
months, list all the facilities that were used:
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
Officer Certification
How many of the departments Officers have their Fire Officer 1 certification or have had Chief’s 101 and one of the 12hour National Fire Academy’s Leadership Classes. (Proof of Certification Required)
_____
Recruit Training
Per the departments policy how many hours of Recruit Training are required by the department the first 12 months for a
new firefighter
_____
New Driver Operator Training
Per the departments policy how many hours of Driver Operator training are required by the department before a
firefighter can drive an engine emergency traffic on a call.
_____
Pre-Fire Planning
Percentage of the completed per-plans of non-residential properties
_____%
How offen are the per-plans updated
_____
Operational Considerations
Does the department have and utilize Standard Operating Procedures Guidelines?
Yes ___
No ___
Does the department have and utilize an Incident Management System?
Yes ___
No ___
Guidelines should include general emergency operations, including response of apparatus, operation of emergency
vehicles, safety at emergency incidents, communications, apparatus inspection and maintenance, fire suppression,
company operations, automatic operations, training, and personnel response.
Fire Department Must Complete Exhibit 3 for Training Credit
Rating Inspection Work Sheet
Complete an Automatic Aid Information sheet for all departments that provide Automatic Aid
into your fire district, on first alarm basis, to structure fires. If the responding department has
multiple stations which provide you Automatic Aid a sheet (exhibit 4) must be completed for
each station that provides Automatic Aid.
Department Name _____________________________________________________________
Physical Address _______________________________________________________________
What is the distance from the Automatic Aid Station to your fire district line________ miles
List the Apparatus unit number of all units responding on a first alarm basis:
Engine (s) ______ / ______ Tanker (s) ______ / ______ /______ Ladder______ Other ______
Does the Automatic Aid department utilize the same communication center as your
department
Yes ____ No____
If you answer NO to the previous question:
Does the Automatic Aid department have common Mobile and Portable Radios communications
with your department
Yes____ No____
Does the Automatic Aid department have common Mobile or Portable Radios communications
Yes____ No____
with your department
What percentage of your fire district, on a first alarm basis does the Automatic Aid department
provide coverage
_______%
List the last four training sessions your department held with this Automatic Aid department:
Date
Type of Training
Hours
1. ____________ ________________________________________________ ______
2. ____________ ________________________________________________ ______
3. ____________ ________________________________________________ ______
4. ____________ ________________________________________________ ______
Exhibit 4, Automatic Aid Sheet must be completed for each station providing Automatic Aid
15
Rating Inspection Work Sheet
Individual Property Fire Suppression
List at least 4 Engines Companies and 1 Ladder Company, within 15 miles, that could assist your department
in the event of a large working fire. These apparatus can come from auto aid departments or can be from
departments which wouldn't normally respond into your district on a first alarm basis.
Outside Aid Fire Companies
Engine Companies
Ladder Companies
Distance
from Fire
Station to
District Line
Pump Capacity
Distance
from Fire
Station to
District Line
Feet of 2 ½ “
or larger
supply hose
Length of Aerial
Ladder or Elevated
Platform
16
Rating Inspection Work Sheet
Water Supply
1. Water System Name_________________________________________
Hydrant, Size and Type
Total number of hydrants and static water points
______
Number of hydrants with 2 – 2 ½” and 1 – 4 ½” outlet with 5 ¼” or larger barrel
______
Number of hydrants with 2 – 2 ½” and 1 – 4 ½” outlet with 4 ½” barrel
______
Number of hydrants on a 4-inch branch line or smaller OR any single 2 ½” hose outlet hydrant
______
Number of certified dry hydrants with 6” pipe or larger (certification documentation required for review)
______
Number of certified suction points (certification documentation required for review)
______
Pressure Hydrant and Static Water Point Inspection Program
Is there an inspection program
If yes, what frequency
Yes _____ No______
1 Year ___
2 Year ___
3 Year ___
4 Year ___
5 Year ___ or greater
Are hydrants flushed during the inspection
Yes _____ No ______
Are hydrants pressure tested during the inspection
Yes _____ No ______
Pressure Hydrant and Static Water Point Flow Testing Program
Is there a flow testing program
If yes, what frequency
Yes _____ No ______
5 years ___ 6 years ___ 7 years ___ 8 years ___ 9 years ___ 10 years or greater ___
Is a calibrated hydraulic modeling program used for this water system
Yes _____ No ______
(certification documentation required for review)
Hydrant Marking System
Is there a hydrant marking system in place
Yes _____ No ______
Exhibit 5 must be completed for all static water points
17
Rating Inspection Work Sheet
Water Supply
2. Water System Name_________________________________________
Hydrant, Size and Type
Total number of hydrants and static water points
______
Number of hydrants with 2 – 2 ½” and 1 – 4 ½” outlet with 5 ¼” or larger barrel
______
Number of hydrants with 2 – 2 ½” and 1 – 4 ½” outlet with 4 ½” barrel
______
Number of hydrants on a 4-inch branch line or smaller OR any single 2 ½” hose outlet hydrant
______
Number of certified dry hydrants with 6” pipe or larger (certification documentation required for review)
______
Number of certified suction points (certification documentation required for review)
______
Pressure Hydrant and Static Water Point Inspection Program
Is there an inspection program
If yes, what frequency
Yes _____ No______
1 Year ___
2 Year ___
3 Year ___
4 Year ___
5 Year ___ or greater
Are hydrants flushed during the inspection
Yes _____ No ______
Are hydrants pressure tested during the inspection
Yes _____ No ______
Pressure Hydrant and Static Water Point Flow Testing Program
Is there a flow testing program
If yes, what frequency
Yes _____ No ______
5 years ___ 6 years ___ 7 years ___ 8 years ___ 9 years ___ 10 years or greater ___
Is a calibrated hydraulic modeling program used for this water system
Yes _____ No ______
(certification documentation required for review)
Hydrant Marking System
Is there a hydrant marking system in place
Yes _____ No ______
Exhibit 5 must be completed for all static water points
Exhibit 6 must be completed if the departments have more than 2 water systems
18
Rating Inspection Work Sheet
Alternate Water Supply Information
This information to be completed if a Fire District is being graded for a lower than class 9 rating and there
are no recognized hydrants or certified water points with a 1000’ of any build upon area in the district.
What alternate method or methods of operation will be used in the Fire District.
Nurse Tanker
Drop Tank Operation
Hose Lay Operation over 1000’
Other
______
______
______
______
Provide a brief description of the different methods that might be used by the fire department to provide a
water supply during a structure fire in the district. The description should include information such as the
number of tankers responding on first alarm, the method in which you plan to fill the tankers, how portable
drop tanks will be used. If an extended hose lay operation is used, you must indicate the longest lay that will
be needed and what equipment will be used in the operation.
The department must provide a description of a recent incident or training session where a certified water
supply was more than 1,000 feet from the fire-site but 250 gpm or more was delivered continuously for more
than one hour. Give the following information.
•
•
•
•
•
•
Location of incident or training ____________________________________________________________
Date of fire or test
____________
Number of water tankers used
____________
Rate of flow delivered
____________
Distance between the fire-site and the water supply site
____________
Time duration where at least 250 gpm was able to be flowed continuously
____________
19
Rating Inspection Work Sheet
Alternate Water Supply Information
Apparatus Used During and Alternate Water Supply Operation
List all the apparatus that will be dispatched on first alarm response to a structure fire in the fire district.
Sta. #
Unit #
Sta. #
Fire Scene Engines
Pump
Capacity
Fill Site Engines
Pump
Unit #
Capacity
Tank
Capacity
Drop Tank
Capacity
Tank
Capacity
Tankers
Sta. #
Unit #
Tank
Capacity
Drop Tank
Capacity
20
Rating Inspection Work Sheet
Community Risk Reduction
Fire Prevention Code and Enforcement
Number of non-residential buildings within your inspection jurisdiction (If a county is
doing inspections for a rural district they should include all the buildings in the county
that they are responsible for inspecting)
____________
Fire prevention and Code Regulations
What fire prevention code is currently adopted by your jurisdiction
________________________
What edition of the adopted code is currently in effect
________________________
Fire Prevention Staffing Frequency of Inspections
Does the district use their own inspectors
Yes ______ No _______
Enter the number of fire prevention inspectors
_______
Enter the average yearly number of fire inspections completed over the past three years
_______
Does the district use county fire prevention inspectors
Yes ______ No _______
Enter the number of fire prevention inspectors
_______
Enter the average yearly number of fire inspections completed over the past three years
_______
Does the district use in-service personnel fire prevention inspectors
Yes ______ No _______
Enter the number of fire prevention inspectors
_______
Enter the average yearly number of fire inspections completed over the past three years
_______
Fire Prevention Certification and Training
Fire Inspection Certification
Enter the number of certified fire prevention inspector’s
Fire Prevention Inspector Continuing Education
Is there a continuing education program for inspectors
Enter the required number of continuing education hours per inspector per year.
_______
Yes ______ No _______
_______
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Rating Inspection Work Sheet
Fire Prevention Programs
Plan Review
What percentage of new nonresidential construction, including remodeling and additions,
receive a plan review of fire prevention and fire suppression features
Are records kept of all fire prevention inspections and used to document
and track inspection activity
_______%
Yes ______ No _______
Certificate of Occupancy Inspections
What percentage of new residential construction receives a fire prevention inspection prior to
issuing the Certificate of Occupancy
_______%
What percentage of new nonresidential construction receives a fire prevention inspection
prior to issuing the Certificate of Occupancy
_______%
Quality Assurance Program for Enforcement and Inspection Programs
Is there a Quality Assurance Program for fire prevention inspections
Yes ______ No _______
How many inspectors participate in the Quality Assurance program
_______
Code Compliance Follow-up
What percentage of initial inspections, with violations, receives follow-up
inspections to verify fire prevention code compliance
_______%
Inspection of Private Fire Protection Equipment
What percentage of private fire protection equipment is inspected on a
routine basis and in accordance with the adopted codes
_______%
Fire Prevention Ordinances
Indicate which fire prevention ordinances below have been adopted: over and above the NC Building Code.
Ordinances
Fire Lane(s)
Fireworks
Hazardous Materials Route
Wildland Urban Interface
Weeds and Trash
BBQ Grills
Ordinance or Code Number
_ _ _ _ _ _ __ _ _ _ _ __
_ _ _ _ _ _ __ _ _ _ _ __
_ _ _ _ _ _ __ _ _ _ _ __
_ _ _ _ _ _ __ _ _ _ _ __
_ _ _ _ _ _ __ _ _ _ _ __
_ _ _ _ _ _ __ _ _ _ _ __
Enforced
Yes ______ No _______
Yes ______ No _______
Yes ______ No _______
Yes ______ No _______
Yes ______ No _______
Yes ______ No _______
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Rating Inspection Work Sheet
Fire Department Training and Pre-Incident Planning Coordination
Is there a defined procedure to share information regarding fire prevention
activities with training and pre-incident planning programs
Public Fire Safety Education
Yes ______ No _______
What is the number of certified fire safety educators
_______
How many of the above Public Fire Safety Education personnel are trained in
Methods of Teaching
_______
Fire Safety Education Continuing Education
Is there a required amount of continuing education hours per year
Yes ______ No _______
If yes, enter the required number of continuing education hours per
person per year.
_______
Residential Fire Safety Program
What percentage of the population in the jurisdiction is reached with fire safety educational
programs each year
_______%
To receive credit in this area the department must provide documentation for review of
fire education programs that have been offered in the last 12 months.
School Fire Exit Drills
Are the schools in the FPA conducting at least 1 fire drill per month during the
Yes ______ No _______
school session
If No, how many months is the school session and how many fire exit drills are they
conducting
Session length (in months) _______
Fire exit drills
_______
Is developmentally appropriate classroom instruction presented on fire safety to
all students in early childhood education
If no, what is the percentage of students who received developmentally
appropriate classroom instruction over the past three years
Yes ______ No _______
______%
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Rating Inspection Work Sheet
Juvenile Fire Setter Intervention
What percentage (averaged over the past three years) of juveniles identified as being involved
in fire-play or fire-setting behavior are referred for intervention services
Large Loss Potential Occupancies
Does the fire department present fire safety education to all occupancies
that have a large loss of life potential or hazardous conditions, such as
high-rise buildings, hospitals, nursing homes, industrial facilities, other
large commercial structures or community risk from wildfires
_______%
Yes ______ No_______
If no, what percentage of the properties like these in your jurisdiction do you reach with
fire safety educational programs each year
_______%
Fire Investigation
Fire Investigation Organization and Staffing
Is an agency established within the jurisdiction with responsibility to conduct fire
cause investigations
Yes ______ No_______
Does the district utilize their investigators/SBI/County Fire Marshal Office/Local
Law Enforcement to investigate suspicious fires
Yes ______ No_______
According to the fire department procedures, what percentage of structure
fires receive a cause and origin investigation
_______%
How many fire investigators are there
_______
Fire Investigators Certification and Training
How many existing fire investigators are certified as Basic Fire and Arson Investigator or
higher following the criteria contained in NFPA 1033, Standard for Professional Qualifications
for Fire Investigator
_______
Fire Investigation Continuing Education Training
Is there a required amount of continuing education hours per year
If yes, enter the required number of continuing education hours per person per year.
Yes ______ No_______
_______
Use of the National Fire Incident Reporting System (NFIRS)
Does the department participate in the NFIRS program
Yes ______ No_______
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