Marietta Fire Department - Incident Report Request

2. Preferred Method of Delivery?*

   1. E-Mail
   2. Fax
   3. Regular Mail
   4. Walk-In

3. Date of Request*
   Date of Request

4. Time*
   Time

8. Requestor Information

10. First Name*

11. Last Name*

13. Address *

15. City*

16. State*

17. Zip*

19. Phone Number*

20. Fax Number if Applicable

22. Email Address*

26. Incident Information for Report
    Fire Incident Reports are subject to open records; however, an emergency medical record/report will require the patient, legal guardian, or power of attorney to provide photo identification. When a person other than the patient requests an emergency medical record/report, a notarized HIPAA authorization form or court order is required. Copies of emergency medical records/reports must be picked up in person.

    Fire Incident Reports are subject to open records; however, an emergency medical record/report will require the patient, legal guardian, or power of attorney to provide photo identification. When a person other than the patient requests an emergency medical record/report, a notarized HIPAA authorization form or court order is required. Copies of emergency medical records/reports must be picked up in person.

28. Type of Incident*
    -- Select One --Building FireVehicle FireFire - OtherEmergency Medical CallMotor Vehicle AccidentWeather Related EmergencyOther

30. Address of Incident*

32. City

33. State

34. Zip Code

36. Date and Time of Incident*
    Date and Time of Incident

    Date and Time of Incident

37. Marietta Fire Incident/Case Number

39. Any Additional Details for Request

41. Government issued photo ID (when required)

42. Authorization Document (when required)

46. Signature of person making the request*

    The City will respond to this request withing five (5) working days.

48. Do you agree?*

    By clicking "I agree," you agree and acknowledge that 1) your application will not be "Signed" in the sense of a traditional paper document and 2) By signing in this alternate manner, you agree that your "electronic signature" is valid and binding upon you to the same force and effect as a handwritten signature.

    1. I Agree
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50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit Submit and Print

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