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Marietta Fire Department - Incident Report Request
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This form has been modified since it was saved. Please review all fields before submitting.
Preferred Method of Delivery?
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E-Mail
Fax
Regular Mail
Walk-In
Date of Request
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Date of Request
Time
*
Time
Requestor Information
First Name
*
Last Name
*
Address
*
City
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State
*
Zip
*
Phone Number
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Fax Number if Applicable
Email Address
*
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.
Type of Incident
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-- Select One --
Building Fire
Vehicle Fire
Fire - Other
Emergency Medical Call
Motor Vehicle Accident
Weather Related Emergency
Other
Address of Incident
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City
State
Zip Code
Date and Time of Incident
*
Date and Time of Incident
Date and Time of Incident
Marietta Fire Incident/Case Number
Any Additional Details for Request
Government issued photo ID (when required)
Authorization Document (when required)
Signature of person making the request
*
The City will respond to this request within five (5) working days.
Do you agree?
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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.
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