"Burn Injury Reporting Form" - Connecticut

Burn Injury Reporting Form is a legal document that was released by the Connecticut State Department of Administrative Services - a government authority operating within Connecticut.

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State of Connec cut 
Department of Administra ve Services 
Burn Injury Repor ng Form
Office of Educa on and Data Management 
www.ct.gov/dcs   |   phone 860.713.5522   |   860‐920‐3093 
To Report Burn Injuries:
1.  Immediately call the Local Fire Marshal in whose jurisdic on the injury occurred. 
2.  Tell the Fire Marshal you are repor ng a burn injury and give the following informa on: 
     
A. Vic m’s name, address and date of birth      D. Area(s) of body injured                                               G. Apparent cause of burn injury 
      B. Address when burn injury occurred                E. Degree of burns and percent of body burned        H. Name and address of repor ng facility 
     
C. Date and  me of injury                                      F. Injury severity                                                               I.  A ending physician 
3.  Complete the Burn Injury Repor ng Form within 48 hours of the incident.  This is a fillable‐form in PDF.  Please complete the 
form electronically and email to:  oedm@ct.gov with the subject line:  Burn Injury Report.  You may also print and mail the form 
to:  Office of Educa on and Data Management, DAS, 450 Columbus Blvd., Suite 1306, Har ord, CT 06103.
Male 
Vic m’s Name_____________________________________  DOB_____________  Gender  
 
 
 
Female 
 
                                               Last, First, MI 
 
 
                  mm/dd/yy 
 
Check if incident has 
received prior treatment 
Vic m’s Address___________________________________________ Vic m’s  Phone________________ 
 
 
(transfer pa ent) 
                                  Number, Street, City, State, Zip 
 
Address Where Burn Occurred_________________________________________________________County_______________ 
 
 
 
 
 
 
Number, Street, City, State, Zip 
 


1st
3rd
Date of Injury_____________   Time  of Injury________ hours    Percent Burned____%    Degree(s) of Burn
Inhala on Burn  
   
2nd
Area(s) of Body Injured (Put and “X” by all that apply)
Injury Severity (Put an “X” in the appropriate box)
____ Face, Head               ____ Leg   
 
 
                Moderate (treated and released)   
               Serious (hospitalized)  
____ Neck, Shoulder        ____ Foot  
 
        
Life Threatening (death is imminent and/or probable)  
____ Chest, Abdomen     ____ Arm   
 
 
         
Dead on Arrival  
____ Back, Bu ocks         ____ Hand 
                                         
____ Groin, Genitals        ____ Internal (including trachea and larynx) 
Apparent Cause of Burn Injury (Put and “X” in the appropriate box)
 Chemical  ‐ Contact or exposure to reac ve, caus c, corrosive or irrita ng substance   
 Contact with Hot Object ‐ Woodstove, stovepipe, furnace, iron, steam pipe, exhaust pipe, etc.   
 Cooking  ‐  Stove, oven, hotplate, barbecue, hot grease   
 Electrical  ‐  Electrocu on, electrical equipment and flash burns   
 Explosive  ‐  Gun powder, TNT, dynamite   
 Fireworks  ‐  Sparklers, firecrackers, rockets, smoke bombs, etc.   
 Flammable Liquids  ‐ Igni on of flammable/combus ble liquids such as gasoline, kerosene, diesel fuel, jet fuel, lighter fluid, etc.   
 Gas/Vapor Explosion  ‐  igni on of flammable gases or the explosion of flammable liquid vapors   
 Hot Liquid  ‐  Hot water, coffee, tea, hot food, hot tar, melted plas c, etc. 
 Other Open Flame  ‐  Welding, matches, lighter, torch, etc. 
 Outside Fires  ‐  Grass and brush, forest, bonfires, dump, trash and refuse fires, etc. 
 Radia on  ‐  Burns caused by contact or exposure to any radioac ve materials 
 Steam  ‐  caused by escaping steam from radiators, boilers, pipes, etc. 
 Structure Fire  ‐  any uncontained burning within a structure, including smoking accidents, trash fires, etc. 
 Sunburn  ‐  Exposure to ultraviolet light, including sun lamps 
 Vehicle Fire  ‐  Car, truck, plane, boat, tractor, lawnmower, etc., carburetor and engine fires, etc. 
Name of Repor ng Facility __________________________________________________   Date of Report ____________________ 
 
 
 
 
 
 
 
 
 
 
 
 
   
mm/dd/yy 
Address of Repor ng Facility __________________________________________________________________________________ 
 
 
 
 
 
                                   Number, Street, City, State, Zip 
Name of A ending Physician ___________________________ Name of Person Comple ng Report _________________________ 
Last, First, MI   
 
 
 
 
 
  Last, First, MI
 
 
State of Connec cut 
Department of Administra ve Services 
Burn Injury Repor ng Form
Office of Educa on and Data Management 
www.ct.gov/dcs   |   phone 860.713.5522   |   860‐920‐3093 
To Report Burn Injuries:
1.  Immediately call the Local Fire Marshal in whose jurisdic on the injury occurred. 
2.  Tell the Fire Marshal you are repor ng a burn injury and give the following informa on: 
     
A. Vic m’s name, address and date of birth      D. Area(s) of body injured                                               G. Apparent cause of burn injury 
      B. Address when burn injury occurred                E. Degree of burns and percent of body burned        H. Name and address of repor ng facility 
     
C. Date and  me of injury                                      F. Injury severity                                                               I.  A ending physician 
3.  Complete the Burn Injury Repor ng Form within 48 hours of the incident.  This is a fillable‐form in PDF.  Please complete the 
form electronically and email to:  oedm@ct.gov with the subject line:  Burn Injury Report.  You may also print and mail the form 
to:  Office of Educa on and Data Management, DAS, 450 Columbus Blvd., Suite 1306, Har ord, CT 06103.
Male 
Vic m’s Name_____________________________________  DOB_____________  Gender  
 
 
 
Female 
 
                                               Last, First, MI 
 
 
                  mm/dd/yy 
 
Check if incident has 
received prior treatment 
Vic m’s Address___________________________________________ Vic m’s  Phone________________ 
 
 
(transfer pa ent) 
                                  Number, Street, City, State, Zip 
 
Address Where Burn Occurred_________________________________________________________County_______________ 
 
 
 
 
 
 
Number, Street, City, State, Zip 
 


1st
3rd
Date of Injury_____________   Time  of Injury________ hours    Percent Burned____%    Degree(s) of Burn
Inhala on Burn  
   
2nd
Area(s) of Body Injured (Put and “X” by all that apply)
Injury Severity (Put an “X” in the appropriate box)
____ Face, Head               ____ Leg   
 
 
                Moderate (treated and released)   
               Serious (hospitalized)  
____ Neck, Shoulder        ____ Foot  
 
        
Life Threatening (death is imminent and/or probable)  
____ Chest, Abdomen     ____ Arm   
 
 
         
Dead on Arrival  
____ Back, Bu ocks         ____ Hand 
                                         
____ Groin, Genitals        ____ Internal (including trachea and larynx) 
Apparent Cause of Burn Injury (Put and “X” in the appropriate box)
 Chemical  ‐ Contact or exposure to reac ve, caus c, corrosive or irrita ng substance   
 Contact with Hot Object ‐ Woodstove, stovepipe, furnace, iron, steam pipe, exhaust pipe, etc.   
 Cooking  ‐  Stove, oven, hotplate, barbecue, hot grease   
 Electrical  ‐  Electrocu on, electrical equipment and flash burns   
 Explosive  ‐  Gun powder, TNT, dynamite   
 Fireworks  ‐  Sparklers, firecrackers, rockets, smoke bombs, etc.   
 Flammable Liquids  ‐ Igni on of flammable/combus ble liquids such as gasoline, kerosene, diesel fuel, jet fuel, lighter fluid, etc.   
 Gas/Vapor Explosion  ‐  igni on of flammable gases or the explosion of flammable liquid vapors   
 Hot Liquid  ‐  Hot water, coffee, tea, hot food, hot tar, melted plas c, etc. 
 Other Open Flame  ‐  Welding, matches, lighter, torch, etc. 
 Outside Fires  ‐  Grass and brush, forest, bonfires, dump, trash and refuse fires, etc. 
 Radia on  ‐  Burns caused by contact or exposure to any radioac ve materials 
 Steam  ‐  caused by escaping steam from radiators, boilers, pipes, etc. 
 Structure Fire  ‐  any uncontained burning within a structure, including smoking accidents, trash fires, etc. 
 Sunburn  ‐  Exposure to ultraviolet light, including sun lamps 
 Vehicle Fire  ‐  Car, truck, plane, boat, tractor, lawnmower, etc., carburetor and engine fires, etc. 
Name of Repor ng Facility __________________________________________________   Date of Report ____________________ 
 
 
 
 
 
 
 
 
 
 
 
 
   
mm/dd/yy 
Address of Repor ng Facility __________________________________________________________________________________ 
 
 
 
 
 
                                   Number, Street, City, State, Zip 
Name of A ending Physician ___________________________ Name of Person Comple ng Report _________________________ 
Last, First, MI   
 
 
 
 
 
  Last, First, MI