Form DFS-K4-1568 "Fire Service Log and Summary of Occupational Injuries, Diseases, and Illnesses" - Florida

What Is Form DFS-K4-1568?

This is a legal form that was released by the Florida Department of Financial Services - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2007;
  • The latest edition provided by the Florida Department of Financial Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DFS-K4-1568 by clicking the link below or browse more documents and templates provided by the Florida Department of Financial Services.

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Download Form DFS-K4-1568 "Fire Service Log and Summary of Occupational Injuries, Diseases, and Illnesses" - Florida

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Page background image
FDID
page __ of __
Fire Service Log and Summary of Occupational Injuries, Diseases, and Illnesses
Dept:
Florida State Fire Marshal, Bureau of Fire Standards and Training
Rpt Period:
All columns reflect fields found on NFIRS 902G version 5 – use same codes as used on 902G
Incident #
Incident Date
Casualty #
Severity
Activity at Time
Primary
Primary Area
Cause of
Factor
Object Involved
Where Injury
Specific
Vehicle Type
mm/dd/yy
C
G3
of Injury G5
Apparent
of Body Injured
Firefighter
Contributing to
in Injury I3
Occurred
Location
J4
Symptom H1
H2
Injury I1
Injury I2
J1
J3
Department Address:
City/State & Zip:
Chief of Department:
Safety Officer:
(Type or Print)
(Type or Print)
Chief Signature:
Safety Officer Signature:
Telephone #:
Telephone #:
DFS-K4-1568
PUB. __/07
FDID
page __ of __
Fire Service Log and Summary of Occupational Injuries, Diseases, and Illnesses
Dept:
Florida State Fire Marshal, Bureau of Fire Standards and Training
Rpt Period:
All columns reflect fields found on NFIRS 902G version 5 – use same codes as used on 902G
Incident #
Incident Date
Casualty #
Severity
Activity at Time
Primary
Primary Area
Cause of
Factor
Object Involved
Where Injury
Specific
Vehicle Type
mm/dd/yy
C
G3
of Injury G5
Apparent
of Body Injured
Firefighter
Contributing to
in Injury I3
Occurred
Location
J4
Symptom H1
H2
Injury I1
Injury I2
J1
J3
Department Address:
City/State & Zip:
Chief of Department:
Safety Officer:
(Type or Print)
(Type or Print)
Chief Signature:
Safety Officer Signature:
Telephone #:
Telephone #:
DFS-K4-1568
PUB. __/07