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DOH-61 (Abuse) NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Community Environmental Health and Food Protection Children’s Camp Program Allegation of Abuse Report Form INSTRUCTIONS: See Environmental Health Manual Procedure CSFP-146 before completing this form. A. FACILITY INFORMATION Facility Facility Code:____ Facility Type: R Day R Overnight R Municipal Day Camp Are 20% or more of the campers developmentally disabled? R Yes R No Date Reported B. EVENT INFORMATION eHIPS Incident (Note: eHIPS will assign when entered into system) Note: If reportable injuries occurred as a result of this incident, complete an injury report form as well Date of Incident Time of Occurrence (Military time) Location where abuse occurred: a. In-Camp b. Out-of-Camp Where did injury occur? Specify for locations marked with an asterisk: a. Amusement park e. Arts & crafts i. Classroom m. Horseback area/trail q. Outdoor sports area u. Recreational hall y. Tenting/campsite area b. Aquatic area* f. Assembly area j. Cookout area n. Indoor sports area r. Parking lot v. Riflery area z. Other* c. Aquatic theme park g. Bathroom/shower k. Dining area o. Kitchen area s. Playground w. Ropes/challenge course d. Archery area h. Camp/trail/road l. Drama/stage area p. Open field/lawn* t. Public highway/road x. Sleeping area Nature of Allegation: ___Physical Abuse Sexual Abuse Both Physical and Sexual Abuse Note: For multiple victim abuse incidents, attach additional sheets containing victim information. C.1. VICTIM INFORMATION - Material in shaded area is confidential eHIPS Victim ID (Note: eHIPS will assign when entered into system) Name of Victim (Last, First, Home Name of Parent or Guardian (Last, First, Home Phone Number: Note: All the above information must be collected and maintained by LHD for appropriate investigation and follow-up. Age: Sex: R Female R Male Status: R Camper R Developmentally Disabled Camper R CIT/Jr. Counselor R Counselor R Other Staff* R Other* Specify What was the victim doing? a. Amusement park rides h. Classroom instruction o. Free period v. Nature study/walk dd. Swimming b. Aquatic theme park rides i. Cooking p. Games-organized* w. Playground equipment activity ee. Transportation c. Archery j. Court/field sports* q. Gymnastics x. Playing ff. Travel between activities d. Arts & crafts k. Dancing/Acting r. High adventure activity y. Riflery gg. Walking/Running e. Bicycling l. Diving s. Hiking aa. Rollerskating/rollerblading hh. Woodcarving/Wood working f. Boating/Canoeing m. Eating t. Horseback riding bb. Ropes/Challenge course ii. Woodcutting/chopping g. Chores n. Fighting u. Martial arts cc. Sleeping z. Other * * 2. Victim Information- (Complete for multiple victims) Number of campers: male____ female____ Number of staff: male female____ Number of others: male female_______ ---PAGE BREAK--- DOH-61 (Abuse) D. SUPERVISION 1. Supervision during incident (indicate as many as apply) a. Activity inadequately addressed in the written plan d. No staff present e. Quality of supervision adequate h. Staff orientation/training for activity not documented/received k. Written plan not followed b. Activity not addressed in the written plan f. Quality of supervision inadequate i. Supervision ratio inadequate z. Other * c. Camper orientation for activity not documented/received g. Staff not trained/knowledgeable as per the written plan j. Supervision ratio correct * E. ALLEGED PERPETRATOR INFORMATION: Attach additional sheets if multiple perpetrators. Name: Sex Information in shaded area is confidential Status: R CIT/Jr. Counselor R Counselor R No relation to camp R Trespasser R Visitor R Camper R Dev. Disabled Camper R Other Staff* R Unknown F. INVESTIGATION Was an On-Site investigation conducted by the Local Health Department? Yes No Date of On-Site Investigation: Did the Local Health Department conduct a telephone follow-up? Yes No Date of Follow-up: G. NARRATIVE- Do not include the full names of people involved with the incident. Use the first and last name initials or other similar code. Allegation of Abuse- Provide a description of the event, conclusions and DOH recommendations: Include statements pertaining to Subpart 7-2 compliance and the acceptability/implementation of the camp written plan. Recommendations should include whether or not administrative action against the camp will be taken as well as the steps that must be taken to prevent similar incidents in the future. See Environmental Health Procedure CSFP-142 for guidance in addition to completing this electronic report. Information received by: Report reviewed by: