"NYS Ofpc Burn Injury Report" - New York

NYS Ofpc Burn Injury Report is a legal document that was released by the New York State Division of Homeland Security & Emergency Services - a government authority operating within New York.

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Download "NYS Ofpc Burn Injury Report" - New York

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New York State Division of Homeland Security and Emergency Services 
Office of Fire Prevention and Control 
 
NYS OFPC Burn Injury Report
(File within 72 hours)
If hardcopy PLEASE print legibly
MUST be filed in accordance with NYS Penal Law Section265.26
VICTIM'S NAME (Last, First, M.I.):
SEX:
MALE
FEMALE
VICTIM’S ADDRESS (Number, Street, Apt.):
DATE OF BIRTH:
CITY, TOWN, POST OFFICE:
STATE:
ZIP CODE:
TELEPHONE NUMBER
ADDRESS WHERE BURN OCCURRED (Number, Street, Apt.):
CITY, TOWN, POST OFFICE:
STATE:
ZIP CODE:
COUNTY
DATE OF INJURY:
PERCENT BURNED:
AREA OF BODY:
%
Face/Head
Leg
Neck/Shoulder
Foot
TIME OF INJURY:
DEGREE OF BURN:
Chest/Abdomen
Arm
st
rd
HRS.
1
3
Back/ Buttocks
Hand
nd
2
Inhalation
Groin/Genitals
Internal
(24 Hour Clock)
APPARENT CAUSE OF INJURY:
INJURY SEVERITY:
REPORTING FACILITY:
NAME OF ATTENDING PHYSICIAN:
ADDRESS OF REPORTING FACILITY (Number, Street, Apt.):
CITY, TOWN, POST OFFICE:
STATE:
ZIP CODE:
 
DATE OF REPORT:
PERSON FILLING OUT REPORT:
NYS DOH PFI #:
CHECK THE BOX IF:
INJURY RECEIVED PRIOR TREATMENT
THIS IS A REVISED REPORT
CLICK TO SUBMIT TO OFPC BY EMAIL
CLICK TO PRINT FORM FOR FAX OR YOUR RECORDS
OFPC OFFICIAL USE ONLY: 
 
 
BURN INCIDENT #: ______________       IMS DATE: ______________ 
OPERATOR: _____________ 
DHSES OFPC Burn Injury Report  
 
Authority: NYS Penal Law Section 265.26 
New York State Division of Homeland Security and Emergency Services 
Office of Fire Prevention and Control 
 
NYS OFPC Burn Injury Report
(File within 72 hours)
If hardcopy PLEASE print legibly
MUST be filed in accordance with NYS Penal Law Section265.26
VICTIM'S NAME (Last, First, M.I.):
SEX:
MALE
FEMALE
VICTIM’S ADDRESS (Number, Street, Apt.):
DATE OF BIRTH:
CITY, TOWN, POST OFFICE:
STATE:
ZIP CODE:
TELEPHONE NUMBER
ADDRESS WHERE BURN OCCURRED (Number, Street, Apt.):
CITY, TOWN, POST OFFICE:
STATE:
ZIP CODE:
COUNTY
DATE OF INJURY:
PERCENT BURNED:
AREA OF BODY:
%
Face/Head
Leg
Neck/Shoulder
Foot
TIME OF INJURY:
DEGREE OF BURN:
Chest/Abdomen
Arm
st
rd
HRS.
1
3
Back/ Buttocks
Hand
nd
2
Inhalation
Groin/Genitals
Internal
(24 Hour Clock)
APPARENT CAUSE OF INJURY:
INJURY SEVERITY:
REPORTING FACILITY:
NAME OF ATTENDING PHYSICIAN:
ADDRESS OF REPORTING FACILITY (Number, Street, Apt.):
CITY, TOWN, POST OFFICE:
STATE:
ZIP CODE:
 
DATE OF REPORT:
PERSON FILLING OUT REPORT:
NYS DOH PFI #:
CHECK THE BOX IF:
INJURY RECEIVED PRIOR TREATMENT
THIS IS A REVISED REPORT
CLICK TO SUBMIT TO OFPC BY EMAIL
CLICK TO PRINT FORM FOR FAX OR YOUR RECORDS
OFPC OFFICIAL USE ONLY: 
 
 
BURN INCIDENT #: ______________       IMS DATE: ______________ 
OPERATOR: _____________ 
DHSES OFPC Burn Injury Report  
 
Authority: NYS Penal Law Section 265.26 
New York State Division of Homeland Security and Emergency Services 
Office of Fire Prevention and Control 
 
HOW TO REPORT BURN INJURIES – “The E-card”
1.
Completely fill in the fields on the other page of this form.
o Section 1 relates to the Victim’s Identification.
o Section 2 relates to the Location WHERE the injury occurred.
o Section 3 relates to the specifics of the injury.
Certain fields are REQUIRED for completion of form:
Victim Name, DOB, County Where Injury Occurred, Date of Injury,
Three fields in Section 3 are DROP DOWN boxes:
COUNTY:
(Where the injury occurred)
 
APPARENT CAUSE OF INJURY:
(CATEGORY: examples of which include)
CHEMICAL: Contact or exposure to reactive, caustic, corrosive or irritant substance 
CONTACT WITH HOT OBJECT: Woodstove, stovepipe, furnace, iron, steam pipe, exhaust pipe, etc. 
COOKING: Stove, oven, hotplate, barbecue grill, hot grease 
ELECTRICAL: Electrocution, electrical equipment and flash burns 
EXPLOSIVE: Gun powder, TNT, dynamite 
FIREWORKS: Sparklers, firecrackers, rockets, smoke bombs, etc. 
FLAMMABLE LIQUIDS: Ignition of liquids such as; gasoline, kerosene, diesel, jet fuel, lighter fluid, etc. 
GAS / VAPOR EXPLOSION: Ignition of flammable gases or the explosion of flammable liquid vapors 
HOT LIQUID: Hot water, coffee, tea, hot food, hot tar, melted plastic, etc. 
OTHER OPEN FLAME: Welding, matches, lighter, torch, etc. 
OUTSIDE FIRES: Grass and brush, forest, bonfires, dump, trash and refuse fires, etc. 
RADIATION: Caused by contact or exposure to any radioactive materials 
STEAM: Caused by escaping steam from radiators, boilers, pipes, etc. 
STRUCTURE FIRE: Involving the components of a building.  Includes; smoking, heating, natural, etc. 
SUNBURN: Exposure to ultraviolet light, including sun lamps 
VEHICLE FIRE: Car, truck, plane, boat, tractor, lawn mower, etc., carburetor and engine fires, etc
INJURY SEVERITY:
(CATEGORY: examples of which include)
MODERATE: Patient was treated and released 
SERIOUS: Patient was admitted /hospitalized 
LIFE THREATENING: Death is imminent and/or probable 
DEAD ON ARRIVAL: 
o Section 4 relates to your facility and treatment of the injury.  
2.
SIMPLY SUBMIT to the OFFICE OF FIRE PREVENTION & CONTROL 
o Click on the RED SUBMIT FORM button to send via email 
o Click the BLUE PRINT FORM to print a hard copy and send via FAX 
 
THE 24 HOUR BURN FAX HOTLINE IS: 1-800-345-5811
 
If you have questions or concerns regarding the Burn Injury Reporting Procedure or “The E‐card” contact 
the Office of Fire Prevention and Control at (518) 474‐6746.  Burn Injury Reports MUST be made via 
EMAIL or FAX, reports will not be accepted at this telephone number.  
DHSES OFPC Burn Injury Report  
 
Authority: NYS Penal Law Section 265.26 
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