GSA Form 53 Gsa Fire Incident Report

GSA Form 53 is a U.S. General Services Administration form also known as the "Gsa Fire Incident Report". The latest edition of the form was released in March 1, 1986 and is available for digital filing.

Download an up-to-date GSA Form 53 in PDF-format down below or look it up on the U.S. General Services Administration Forms website.

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GSA FIRE INCIDENT REPORT
SECTION I - INCIDENT (Complete for all incidents)
TYPE OF TRANSACTION (Check one)
A
NEW REPORT
MODIFY REPORT
DELETE REPORT
INCIDENT NO.
REGION NO.
MO.
DAY
YR.
DATE OF WEEK
ALARM TIME
B
BUILDING NAME AND ADDRESS (Street, City, State, ZIP Code)
BUILDING NO.
FIXED PROPERTY (Office, warehouse, etc.)
C
MOBILE PROPERTY TYPE
TYPE OF INCIDENT
OCCUPANTS WERE (Check one)
D
A
B
C
D
NOT EVACUATED
EVACUATED
RELOCATED
BOTH B AND C
FIRE DEPARTMENT
DID THE FIRES DEPARTMENT RESPOND? (Check one)
FIRE DEPARTMENT
E
RESPOND WITHIN MIN-
CALLED VIA
YES
NO
UTES OF NOTIFICATION
BRIEF HISTORY OF INCIDENT (Cover all important details - attach additional sheets as needed. Photos and/or sketches may be included.)
F
ACTION(S) TAKEN AND RECOMMENDATIONS TO PREVENT RECURRENCE
G
PERSONNEL
NO. OF INJURIES
NO. OF DEATHS
LIST ACCIDENT NUMBER(S) (GSA Form 3090 for all injuries and /or deaths)
H
GSA
OTHER
$ LOSSES
GSA
OTHER FEDERAL
NON-FEDERAL
BUILDING
I
CONTENTS
EVACUATION
OTHER
SECTION II FIRE (Complete for all fires)
AREA OF FIRE ORIGIN
EQUIPMENT INVOLVED IN IGNITION
J
FORM OF HEAT OF IGNITION
TYPE OF MATERIAL IGNITED
FORM OF MATERIAL IGNITED
K
METHOD OF EXTINGUISHMENT
LEVEL OF FIRE ORIGIN
L
SECTION III - STRUCTURE FIRE (Complete if structure fires)
EXTENT OF FLAME DAMAGE
EXTENT OF SMOKE DAMAGE
M
SPRINKLER PERFORMANCE
DETECTOR PERFORMANCE
N
TYPE OF MATERIAL GENERATING MOST SMOKE
AVENUE OF SMOKE TRAVEL
IF SMOKE
O
SPREAD
BEYOND
FORM OF MATERIAL GENERATING MOST SMOKE
ROOM OF
P
ORIGIN
SECTION IV - PROPERTY
MOBILE PROPERTY
YR.
MAKE
MODEL
SERIAL NO.
LICENSE NO. (If any)
Q
EQUIPMENT INVOLVED IN IGNITION
YR.
MAKE
MODEL
SERIAL NO.
VOLTAGE (If any)
R
SECTION V - PREPARER OF THIS REPORT
INVESTIGATOR'S SIGNATURE
DATE
S
GENERAL SERVICES ADMINISTRATION
GSA
53
FORM
(REV. 3-86)
GSA FIRE INCIDENT REPORT
SECTION I - INCIDENT (Complete for all incidents)
TYPE OF TRANSACTION (Check one)
A
NEW REPORT
MODIFY REPORT
DELETE REPORT
INCIDENT NO.
REGION NO.
MO.
DAY
YR.
DATE OF WEEK
ALARM TIME
B
BUILDING NAME AND ADDRESS (Street, City, State, ZIP Code)
BUILDING NO.
FIXED PROPERTY (Office, warehouse, etc.)
C
MOBILE PROPERTY TYPE
TYPE OF INCIDENT
OCCUPANTS WERE (Check one)
D
A
B
C
D
NOT EVACUATED
EVACUATED
RELOCATED
BOTH B AND C
FIRE DEPARTMENT
DID THE FIRES DEPARTMENT RESPOND? (Check one)
FIRE DEPARTMENT
E
RESPOND WITHIN MIN-
CALLED VIA
YES
NO
UTES OF NOTIFICATION
BRIEF HISTORY OF INCIDENT (Cover all important details - attach additional sheets as needed. Photos and/or sketches may be included.)
F
ACTION(S) TAKEN AND RECOMMENDATIONS TO PREVENT RECURRENCE
G
PERSONNEL
NO. OF INJURIES
NO. OF DEATHS
LIST ACCIDENT NUMBER(S) (GSA Form 3090 for all injuries and /or deaths)
H
GSA
OTHER
$ LOSSES
GSA
OTHER FEDERAL
NON-FEDERAL
BUILDING
I
CONTENTS
EVACUATION
OTHER
SECTION II FIRE (Complete for all fires)
AREA OF FIRE ORIGIN
EQUIPMENT INVOLVED IN IGNITION
J
FORM OF HEAT OF IGNITION
TYPE OF MATERIAL IGNITED
FORM OF MATERIAL IGNITED
K
METHOD OF EXTINGUISHMENT
LEVEL OF FIRE ORIGIN
L
SECTION III - STRUCTURE FIRE (Complete if structure fires)
EXTENT OF FLAME DAMAGE
EXTENT OF SMOKE DAMAGE
M
SPRINKLER PERFORMANCE
DETECTOR PERFORMANCE
N
TYPE OF MATERIAL GENERATING MOST SMOKE
AVENUE OF SMOKE TRAVEL
IF SMOKE
O
SPREAD
BEYOND
FORM OF MATERIAL GENERATING MOST SMOKE
ROOM OF
P
ORIGIN
SECTION IV - PROPERTY
MOBILE PROPERTY
YR.
MAKE
MODEL
SERIAL NO.
LICENSE NO. (If any)
Q
EQUIPMENT INVOLVED IN IGNITION
YR.
MAKE
MODEL
SERIAL NO.
VOLTAGE (If any)
R
SECTION V - PREPARER OF THIS REPORT
INVESTIGATOR'S SIGNATURE
DATE
S
GENERAL SERVICES ADMINISTRATION
GSA
53
FORM
(REV. 3-86)

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