SAFENET

Event Start Date:*

Format mm/dd/yyyy

Event Start Time:*

Format hhmm Military Time

Event Stop Date: 

Optional - if used, Format mm/dd/yyyy

Event Stop Time: 

Optional - if used, Format hhmm Military Time

Incident Name:*

Fire Number: 

P-Code or 4 digit Fire Code

State:*

-- Select State -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Jurisdiction:*

-- Select Jurisdiction -- BIA BLM FWS NPS USFS State Other Unknown

Local Unit: 

Administrative unit (district, park, reserve, etc.) where the event occurred.

Incident Type:*

Wildland Prescribed/Fuels Treatment All Hazard Training Work Capacity Test

Incident Activity:*

Line Support Transport to/from Readiness/Preparedness

Stage of Incident:*

Initial Attack Extended Attack Transfer of Command Mop Up Demobe Non-incident Other

Position Title: 

Firefighter, Division Supervisor, Facilities Unit Lead, etc

Task: 

Line Construction, Structure Protection, Camp Activities, etc

Management Level:*

1 2 3 4 5 N/A
Incident Types 1, 2, 3, 4, 5

Resources Involved: 

Crew, Equipment, Overhead, etc

Contributing Factors:*

Fire Behavior Communications Equipment Environmental Human Factors Other

Human Factors: 

Decision Making Leadership Risk Assessment Fatigue Performance Situational Awareness
Required if Contributing Factors is "Human Factors"

Other Factors: 

Required if Contributing Factors is "Other"

Describe in detail what happened including the concern or potential issue, the environment (weather, terrain, fire behavior, etc), and the resulting safety issue.*

Reporting Individual : please describe actions you took to correct or mitigate the unsafe event.*

You have the right to report unsafe conditions anonymously, in accordance with 29 CFR 1960. You will have the opportunity to print a copy of this SAFENET on the next screen. You are encouraged to share a copy with your supervisor or other affected resources.

Name: 

Optional

Phone: 

Optional

EMail: 

Optional

Agency:*

-- Select Agency -- BIA BLM FWS NPS USFS State Other

State Agency: 

-- Select State Agency -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Required if Agency is "State"

Other Agency: 

Required if Agency is "Other"

Photos, particularly for equipment related issues, may be attached. Please do not exceed 5 pictures and compress photos for the smallest file size that illustrates the particular concern. Photos are subject to the same sanitization criteria as SAFENETs. Allowed files types are JPG, GIF, PNG, PDF, DOC, DOCX and TXT.

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