SECTION 1 – Landowner Information
Landowner Name:
Address:
City:	State:	Zip:
E-mail:	Phone:
SECTION 2 – Tract Information
Tract Number:	Parcel:	Acres:
Property Location:
(attach map)	Latitude:	Longitude:
SECTION 3 – Objectives of the Burn
Reason for the Burn:	Site Prep	Fuel Reduction	Wildlife
Objectives:
SECTION 4 – Fire Breaks
Identify type, location and planned stabilization if needed (identify on the attached map):
SECTION 5 – Weather
Prescription Parameters:
A.	Surface Wind:	D.	Relative Humidity (%):
Direction	MPH
B.	Transport Wind:	E.	Temperature:
Direction
C.	Mixing Height (feet):	F.	Cumulative Severity Index:
Burn Day:	Forecast	On Site
Day	Night	Prior	At Conclusion
A.	Surface Wind:
Direction	MPH	Direction	MPH	Direction	MPH	Direction	MPH
B.	Transport Wind:
Direction	MPH	Direction	MPH
C.	Mixing Height (feet):
D.	Relative Humidity (%):
E.	Temperature:
F.	Cumulative Severity Index:	No burning when CSI is at or above 500 during the growing season or when CSI is at or above 300 during the dormant season.
SECTION 6 – Screening for Smoke Sensitive Targets	Use double 30-degree template. Attach map.
A.	None within 20 miles:	Proceed with burn, follow recommendations to reduce smoke impact, monitor burn until no smoke concerns are present.
B.	Target(s) within 10 to 20 miles:	The following minimum conditions must be met, and the above-mentioned recommendations should also be followed.
C.	Target(s) within 10 miles: SPECIAL CAUTION IS NECESSARY	All of the conditions in A and B above must be met and the following should be considered. The distance to the target, nature of the target, size of the burn, amount and nature of the fuel, fuel moisture, topography, and presence of organic soil. These factors along with the meteorological conditions all combine to determine the quantity and duration of the smoke produced.
SPECIAL CAUTION IS NECESSARY
For all prescribed burning, mixing height will be a minimum of 500 meters or 1,640 feet. In addition, the ventilation rate needs to exceed 14,999 (mph-ft.); calculated as shown: Mixing Height (ft.) X Transport Wind Speed (mph) = Ventilation Rate (These indices are provided in most NWS fire weather forecasts.)
An alternative to burning may need to be prescribed unless conditions change allowing the potential target(s) to not be impacted by the smoke from your burn.
SECTION 7 – Other Considerations
A.	Department of Forestry Regional office notified, as well as county fire department dispatcher.
B.	Homeowners within 1,000 feet. (Permission required through the Emission Standards for Open Burning according to the State Air Pollution Control Board.)
C.	Local Ordinances and the Forest Fire Laws of Virginia.
D.	Keep fires out of large piles of debris and sawdust piles which may produce smoke for extended periods of time. It is DOF policy not to burn bulldozed piled debris as a site preparation method.
E.	If smoke does cross a road you need to place a flag person at both ends with radio communications.
F.	Burn to be completed 1 hour prior to sunset.
G.	What are the fuel conditions and characteristics?
SECTION 8 – Burning Plan / Strategy
A.	What is the complexity of your burn? Briefly identify the ignition, holding and suppression resources needed, the number of personnel and types of equipment required to safely and efficiently accomplish the burn.
B.	Ignition Pattern (starting Point shown on map):
C.	Ignition Method:	Drip Torch	Aerial	Other:

D.	Special Ignition, Control and Smoke Considerations:
E.	Planned Mop-up Activities:
SECTION 9 – Prepared By
Preparer Name (Print)	Preparer Signature	Date
Certification Number:	Phone:
SECTION 10 – Evaluation Immediately After the Burn
1.	Acres Burned:
2.	Spotting:	Distance (comments):
3.	Escapes:
4.	Objectives Met:
5.	Smoke Problems:
6.	Percent Understory Vegetation Consumed:	< 25%	25-50%	51-75%	>75%
7.	Percent Material >3 in. Diameter Consumed:	< 25%	25-50%	51-75%	>75%
8.	Percent of Area with Crown Discoloration:	< 25%	25-50%	51-75%	>75%
9.	Live Crown Consumption:
10.	Adverse Publicity:
11.	Comments:
Evaluator Name (Print)	Evaluator Signature	Date

SECTION 11 – Evaluation in the Future
1.	Insect/Disease Damage:
2.	Tree Mortality:
3.	Percent Understory Kill:	< 25%	25-50%	51-75%	>75%
4.	Soil Movement:
5.	Comments:
Evaluator Name (Print)	Evaluator Signature	Date