~ IMAGETREND

~tiRE
A

BRIDGE

I RC271

FOlD

~ I o4 111s
Slatt

11 2o16

I I MOF2 I

lrOdcniDil!t

1201601 684

hOd'tt'illl~t

S111ion

, NFIRS-1
Basic

E.rpcl""

eemUITract L__j -LJ

~!~~~~~:=:,.~~s~~rca~:"t~'=t,:'~rd~ Fi~

Location Type
X Street address
Intersection
In front of

Rear or

12200
~1/LBepoct

I L.J
I 69TH AV
Prer:.

I I MOLINE

'="
s.._.:..:..,~.:..:,;H"9
_;.
....
.:..;_y_ _ _ _ __ _ _ _ _ __ _ _ _ _ _ __ _ __

f-Pt.IS~ootfl

I L__j L__j

_J

SttHI.T)'iM

~ 161265
Sift

Cky

Sutb

1-L_J

~Code

Adjacent to

Directions
US National Grid

c
D

InJUry

'-"'=-:-::::-c-:-:----,--,--,--.--JI
.:-:
.
----

Mutual aid received

Automatic aid received

Mutual aid given

Automatic aid given

Ch(-Qb;u l
!:!:
!: lhl:

JJMm

I
I

The~

Alarm

Monlh

Day

~~u ~~ rr~~

l..!.:_j

Hour Min Sec

Year

Shifts and Alanns

[2_j

I
I

1 o1 :1? :o1

Dalt .

IL.J
,..,.. ....,
I

FDIC

E2

Loeolo,-n

Aid Given or Received

l.li:lni;t'(k CICCO

Dates and Times

f ~~tS cal, exduding vehide accident with

E1

Incident Type

Thri'"lnci:!trtN~

Arrival

1o1:24:44

Controlled

L__j

LaS1 Unit
Cleared

Other aid given

:SI'i~or

L.J I M053 I
"''~
""""'

"'"""
EJ Special Stud ie s
L~~

SpK2JSiudyiOII'

1o2:16:o8

I I

Spot'ci:I/St..d) VWt

None

Actions Taken
F
l2..j I Eme rgency medical services, other

G2

Resources

1 X ~~...::nt~~~P::~!.blod;
lolodulotllu'-".

Pr.m.arrk:tionTaktt~!1)

Suppression
EMS
Other

Apparatus

LOSSES ~~::!::::.~ kr.:TM..

Personnel

l..!...._____j l2.___j
l..!...._____j [3__j
~ l.2..__j

Cht:drb:l r ilrt.l..o~lc"n.wa
Wd..dt-d1~rrw.ourcn.

Completed Modules
Fire-2

Sln!cture

Fir~3

Civiian Fll'e

Cas.~

Fire Service Cas.S

H1
Fire
Service
Civilian

EMS--6

Wldlend Fire-8

~on--11

Injury

~~
l__j L____j

Detector

H.uMat7

X Appa~t!Js.-9
X Perunnd--10

Casualties
Death

R~l.lrtdlc:;on~f.tH .

Detector alerted occupants

f1SI Non

HJ
0

Estimated Dollar Losses and Values

Property S
Contents S

None

1! - - - - - - - -J'

PRE-JNCIDEcN-T_V_A_L_U_E_:_o-~-...,-.---'
Property

Contents S

l~------~
J

Hazardous Materials Release

Special HazMatactions required or spil :>-=55 gal.

Mixed Use Property

00

Mixed use , other

NabJr11l ge.s: slow leak. no evac. or Hazhlat ac1ion5

10

Assembly use

Propane gas leu lhan a 211b. tank

20

Educational use

Gasoiine vehide fuel tank or portable container

JJ

Medical Ue

Kerosene- fuel-burning equipment/portable storage

40

Ruidentialv se

Diesel (!Jdlfvel oi vehide fuef tani-Jportable

51

Row of stores

House:hofdlonice solvent or chemical spil

53

Endosed mil

Oetedor did not alert occupants

Motor oil.from engine or ponable container

58

Business and residential use

Unknown

Paint spils le:ss lhan 55 galons

59

Office use

Non

60

Industrial use

63

M ilit~ryuse

65

Fa"" use.

NN

Not mixed

U511!:

Paee 1 of 4

Property Use

Structures
t 31

Church, mosque, synagogue, temple, chapel

161

Restaurant

162

Bar ornlghtdub

Of

cafeteria

21 J

Elementary school, inducing kindergarten

215

High

schooV.~.mior

high school/middle sdlool

342

Doctor, dentist or oral surgeon ollic;e

571

~l!:fVI C~

361

Jail, prison (not j.Jvenile)

579

Motor vehide or boat sales, services, repair

419

I or2familydwelling

599

Business office

429

Muttifamily cf'rwlling

615

Electric-generating plant

439

Boarding:/rooming house, residential hotels

629

labora\01)1 or science laboratory

449

Hotel/motel, comm!:rcia/

700

Manufacturing , processing

livestock, poultry storage

2.C 1

Adult education center, college dassroom

459

Residential board and care

819

24-hour care Nursing homes, 4 or more persons

46.(

Barracks, dor mitory

882

Parking garage, general vehicf~

331

Hospital medical or psychiatric

519

Food and beve111ge sales , grocery store

891

warehouse

936

Va.cantlol

981

Construction site

Playground

938

Gl"llded lind cared-for plots orland

984

lnd\Jstrialplanlylltdllrea

Outside
655

Crops or orchard

946

lake, river, s tream

669

Forest, limberland, wood and

951

Ra ilroad right-of-way

l ooltup ancfl!nt.tr:a
PrapciT)'U..ecodeancf
ciHCripcionllfWylf)'CIU

807

0\Jt!iide material storage area

960

Street, other

Nw.NOTU!K.kedl

Dump, sanitary landfil

961

Highway or divided hiQhv.-ay

Open land or ield

962

Residential street, road or residential driveway

K1

L,-~-.,.-"-.-~--:-r,,-,.-":-"'"'l------------'
""

L_j

t"

loatiol\ (~~~~6).

Then \kjp the lhrH

d~l.l!addrnslrcs .

1~-..._

Pou Oll'a

LJ
Stale

_ _ _ _ _ _--.~1

Fru ,

rUTibr

PttU
So~

tit'larHigh...y
AptJSui.:.e~oom

., ,.. .

ely

1-L_J

ZipCodt

Owner

lo~tioti(Stctionllj.

Thtn Pcipthtttv'H
dupble:addl'll!ufne,.,

Authorization

._1"""_2_s_~_r_..._

__

loltrrbtrl.talcirl;ro::pon/0

I I LT
I I LT

P~ornnk

__.1

j";;t;n Heller
SipNitt.n

POiiticlnMnlllc

I I Station 12
I I"""=-'
Station 12

"""'""""

~ ~~~
I j'~ 1 {'15 1 {':io1s 1
M=nth

[hy

Remarks

'""'""'""

Ph<:nt' ll lll'nber

ru

I IL ______________________._..._.._T_,..___'"_""_~I

loeoiOp<lon

10

m Code

U L
I __ _ _ _ _ _ _ _I L_j
~
J L ___

Chedr UW bor if urnt

ldclro::Pnh."i:1crc

1 ~26;;,;7..;:2;_,__-----ll I John Heller

~,

f Airaaft taxiway

I L_j -L_J-L_j

Perso n/En tity In volved

loalOp<lon
Chedcthis borifu.rnt
ldcfrtunrci:lml

K2

Property use

Pn:lptiT)'UWBc.E.

919
931

~t~~ --- ..

311

12-t

'> I<IU V1o 0

T12 arrived first and began pt care pt was carried down from airplane by pts body guard. T12 drove A13 to hospital.

'l't'1r

I RC271

IRes~~rcesll

FO<O

Apparatus or Resource

loldrU91"tilOOOO

Dates and Times

CheckifW UrN diU
l.lo~_y/'l'car

IDIAMB13
Type l 76

Dispatch X

04/15/2016

Arrival

04/15/2016

Type l 12

Sent

Number of

People

the Bnle l.lod<k(81od.EI}

11 o117
11 o126

04/15/2016

ll 0216

04/15/2016

Arrival

04/15/2016

Clear

04/15/2016

11 o117
11 o124
11 o151

Apparatus Use

Actions Taken

Check ONE boJ: lolu.ch

LJaup1o<1 a<;tic:m for ut:h :;app a rr.u~arduch

pti'KinOri.

l~raivf.IO~f:Z'..e ArnM\UW

allhe~rt.

Holoi7Ui1

Dispatch X

Clear

IDI TK12

at Ahrmda~c Oft

Other

Sent

l__2_j

Suppression

X EMS
Other

Sent

L..2_j

X Suppression
EMS

L_j
L_j

L_j
L_j

L_j
L_j

L_j
L_j

Pa!!e 3 of 4

I RC271

1 ~V
lnciHnl C4tt

FD<D

Apparatus o r Resource

I VV I vv-.

loc:id t tf.HU!T'bct

Sent

Dates an d Times

Number of

People
!!~~!'!':!'

IDI AMB 13

Type l76

Pe rso nn eii D

Arrival

Clea r

1o4t15t2016
1o4t15t2o1s
1o4t15t2016

2709

Apparatus or Resource

11 o1 17

11 o126
11 o216

----- - -

Name

FrederikSen. JuStiil
. scirily. Kevin

2698

Dispatch X

Rank Or Grade

Sent

ID I TK12

I
I

Type l 12

Person neiiO

2672
2625
2682

Act ion Taken

Actio n Taken

Action Taken

Actio n Take n

L_j
L_j

' FFP
FFP

Sent ;

Number of

Apparatus Use

Actions Take n

ChK:kOO E bo1 f n ch
lJQ upao.Caaicm lioruc.h appilrlhH ar.d r ad'l
lpp.ar11M IO h!'<2!ci:srr.&int:u pen.onntl
Jl l lheincidt.tf..

--~~~JY~-

citiier

Sen t

1o4t15t2o16

Arrival

X I 04/15/2016

11 o124

Clear

X I 04/15/2016

11 o151

Name

LJ
LJ

Suppression

X EMS

Dates and Tim es

Actions Taken
iJJtuplo( 1ctionl: fDtndlpparato.AJndu.;t,

ilppi11'11l.reloltl6ic-at t b1Ninuw ptrcotYIII'I..

Other

L1......J

Peo ple

Apparatus Use
C hc-d:ON E bo:l:fotru:h
ltthe ioddtfL

Hc~rn.ttl

Ra nk Or Gra d e

Action Taken

L...2._j

Actio n Taken

X Suppression
EMS
Act ion Taken

L_j
L_j
Actio n Taken

Heiler, Jotin
i-ioUiemga,-scott
Leone~ MarCo

Paee 4 of 4

Mo lin e Fire Depa r t m e nt

Comprehe nsive Report

1630-Bth Ave
Moline, I L 6 126 5

Incident Date : 04/15/2016

I!

--

I
II

I
Unit Personnel
Zr;w
- M
- em
_ b_e_r - - - - - - - - - - - - - - - - - *Crew

i - - -- - - -

M embe ;L;v~-,-----

iParamedic

_Frederiksen, Justin
'Ra nds, Austin

_Paramed ic

------- --------

- --~~~Me;b~~~ -

-- ------- ----- - -- -- -

;secondary Careg iver

-~------------------i-;P-ri_m_a_ry
_C:__a-re-g-iv...;e:...r-----------------1

-Sorby,
- '--------------------+------Kevin
Paramedic

====-=-==-==-=-=--=========--Person a l Protective Equipment Used: Gloves

I nc. Date: 04/ 15/201 6

.. _

Moline Fire Department

Page: 1
Date Printed : 04/22/2016 11:23

---!--

-~--- ---;

--h---- ----------~

--------------------------

_I

----~
I

-----------r--------,

Inc. Date: 04/15/2016

.. _

Moline Fire Department

Page: 2
Date Printed: 04/22/2016 11:23

.-----

'

Inc. Date: 04/15/2016

--

Moline Fire Department

Page: 3
Date Printed: 04/22/2016 11:23

--

---- ~-- ---------------------~-~-,

-------------

------

------~- - -- - ~ ~----.....,

---- --- --------------------~-------.JI

--------J.I
- ----~-!!L---------

----------- - - - - - - -

- - -

-----------------------------------------------------

...J

r--

--=-~=1

I
[
- ~==-=--~~-=
:=!..."='"==-~-=-..A::_= ------'=-:J"=-

Inc. Date: 04/15/2016

--

Moline Fire Department

=<.'"..";".-

Jf

Page: 4
Date Printed: 04/ 22/2016 11:23