Fireworks Injury Reporting

INSTRUCTIONS: 1. Print information to ensure legibility.

2. Fill in circles for appropriatechoice.

3. Complete all items on the forms.

CONFIDENTIALINFORMATION

4. Per HEA 1131,reportmust be completedwithin 5 business days after examination of the injury.

Section 1: DemographicInformationon Injured Person

Date of Medical Evaluation: ______

LastName:______FirstName:______MI:______Phone Number: ( ) - Dateofbirth:______Age:______If child, name of parent or guardian(Last, First, MI):______StreetAddress:______City/Town:______State:______ZIP:______County:______

Sex:Race (chooseallthatapply)Ethnicity

οMaleοWhiteοHispanic orLatino

οFemaleοBlack or African AmericanοNotHispanicorLatino

οUnknownοAsian

οNative Hawaiian or Other Pacific

Islander

οAmerican Indian or Alaska Native

οMultiracialοUnknown

Section 2—Site of Report: Hospital / Emergency Department / Physician Office / Surgical Center

οHospitalName:______

οHospital / Related Site:ο Emergency DepartmentοUrgentCareCenter

οAmbulatorySurgicalCenter(Name):______

ο If reporting from a Health Care ProviderOffice,StateNameofPractice:

______PhysicianName:______Contactthrough: οEmail:______ο Office:( ) - ______

StreetAddress:______

City/Town:______State:______ZIP:______County:______

(PersonReporting) Title: ______

LastName:______FirstName:______

Phone Number: ( ) - Email:______

NameofInjuredPerson:______

Section3:InjuryandSurroundingCircumstances

Body Part Involved (note all involved)Type of Injury (note all involved)

οHand(s)/FingerοBurn

οArmο1stDegreeο2nd Degreeο3rd Degree

οEye(s)οContusion/Laceration/Abrasion

οFace / Ears / HeadοPuncture Wound

οLeg(s) / Foot / Toe(s)οPenetrating Foreign Body / Missile

οTrunkοSprain / Fracture

οOther

______

οOther

______

Outcome (note all that apply)Circumstances of Injury

οDeathDateofinjury:______

οEvaluatedinEmergencyDepartmentTimeofinjury:______οAMοPM

οReleasedtohome

οAdmitted to hospitalLocale of injury:

οTransferred to

______

ο Private home / yard / property

οFriend / neighbor / relative home / yard /

property

οEvaluated in provider officeο Public park / street / property

οReleasedtohomeοSchool property

οAdmitted to hospitalοOther

(Specify)______

οOther (Specify)

If hospitalized:If eye injury:

Dateofadmission:______οNoeyeprotection

Dateofdischarge:______

(if available)

οEyeglassesorsafetyglasses

οContact lenses

RiskFactorsatthetimeofinjuryTypeofFireworks/Pyrotechnics

οAlcoholConsumptionοFirecrackers

οBy injured personοRockets (i.e., bottle rockets)

οWithin3hoursofinjuryοSparklers

οBlood alcohol testedοTwisters / “Jumping Jacks”

οUnknownοLightinggunpowder

οBy other people at the sceneοHomemade, altereddevice

οIfinjuredpersonislessthan18yearsof age, wasanadultpresent?

οYes

οNo

οUnknown

οAerial devices

οOther(fountains,romancandles,etc.)

οPyrotechnics (indoor fireworks event) –

Specify Event or Location involved

______

οInjuredpersonwasabystanderοUnspecified / Unknown

Mechanism / Problem (if known)Comments / Additional Information

οMalfunction / timing of firework

οErrant path of rocket

οDebris from aerial fireworks

οMishandling(relighting,throwing,etc.)

οOther

οUnknown

Please fax this form to (317) 233-7761: Attn: Injury Epidemiologist

Or mail to: Indiana State Dept of Health

2 North Meridian Street, 2 Selig

Indianapolis, IN 46204

Please direct any questions to (317) 234-6325