Line Of Duty Death

Line Of Duty Death Submission Form

Use this form to provide initial notification to the Arkansas Fallen Firefighters Memorial of an on-duty firefighter fatality.

Step 1 of 2: Fire Department information. Please complete the fields below and provide us with the details of where the decedent served.

Department Name(*)

Enter the Fire Department or Organization the firefighter was associated with.

Department Chief

Invalid Input

Department Address

Department Address Line 2

Invalid Input

Department City(*)

Enter the city where the fire department is located

Department State(*)

Choose a state from the list

Department Zip Code

Enter a valid US zip code

Department Phone(*)

Please enter a valid 10-digit US telephone number.

Enter the department phone number above.

Name/Rank of Point of Contact(*)

Enter the name and rank of the department point of contact

Point of Contact E-mail Address(*)

Invalid email address.

Fallen's First Name

Please type the first name of the firefighter.

Fallen's Last Name

Please type the last name of the firefighter.

Funeral Arrangements

Enter some text

Step 2 of 2: Incident Characteristics

Please complete the selections in the form below, and provide a summary of the incident if desired.

Hometown Heroes

Yes Check if applicable

Check if Firefighter was off-duty and died within 24 hours after engaging in non-routine stressful or strenuous physical activity while on duty (Hometown Heroes Act).

Terrorism Incident

Yes Check if applicable

Check if the incident where the fatality occurred was a terrorist incident.

Associated with Wildland

Yes Check if applicable

Check if the incident where the fatality occurred was a wildland incident.

Wildland Incident Name

Invalid Input

Suspicious / Arson Fire

Yes Check if applicable

Check if the incident where the fatality occurred was suspicious in nature or was ruled an arson fire.

Fixed Property Use