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DOH-61h (2/03) NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Community Environmental Health and Food Protection Children’s Camp Program Multiple Victim Injury Report Form Instruction: See Environmental Health Manual Procedure CSFP 146 and back of form prior to completing Camp Name: eHIPS Incident Number: Address: Incident Date: VICTIM INFORMATION: Name of Patient: Home Address: Name of Parent or Guardian Home Phone Number ( ) **Shaded information is confidential Age (years): Sex: R Female R Male eHIPS Victim Number: (assigned by eHIPS) Status: R Camper R Developmentally Disabled Camper R CIT/Jr. Counselor R Counselor R Other Staff* R Other*(Specify) 1. What was the victim doing? Other* (specify) 2. Injury: Injury Type *Specify Area Injured *Specify Cause of Injury *Specify (question 2a) (when required) (question 2b) (when required) (question 2c) (when required) First Injury Second Injury Third Injury Fourth Injury 3. Treatment: Who *Specify Where *Specify What *Specify (question 3a) (when required) (question 3b) (when required) (question 3c) (when required) Treatment Provider #1 Treatment Provider #2 Treatment Provider #3 Treatment Provider #4 VICTIM INFORMATION: eHIPS Victim Name of Patient: (Last, First, M.I.) Home Address: Name of Parent or Guardian (Last, First, Home Phone Number ( ) **Shaded information is confidential 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) 1. What was the victim doing? Other* 2. Injury: Injury Type *Specify Area Injured *Specify Cause of Injury *Specify (question 2a) (when required) (question 2b) (when required) (question 2c) (when required) First Injury Second Injury Third Injury Fourth Injury 3. Treatment: Who *Specify Where *Specify What *Specify (question 3a) (when required) (question 3b) (when required) (question 3c) (when required) Treatment Provider #1 Treatment Provider #2 Treatment Provider #3 Treatment Provider #4 ---PAGE BREAK--- DOH-61h (2/03) Instructions: Use this form as a continuation of the DOH-61 form to collect injury information for multiple victims whose injuries are associated with a single event (i.e. vehicle collision) 1. What was victim doing? a. Amusement park rides k. Dancing/acting u. Martial Arts ff. Travel between activities b. Aquatic theme park rides l. Diving v. Nature study/walk gg. Walking/running c. Archery m. Eating w. Playground equipment activity hh. Woodcarving/wood working d. Arts & Crafts n. Fighting x. Playing ii. Woodcutting/chopping e. Bicycling e. Boating/Canoeing f. Chores g. Classroom instruction h. Cooking i. Court/Field sports* o. Free period p. Games – organized* q. Gymnastics r. High adventure activity s. Hiking t. Horseback riding y. Riflery aa. Rollerskating/rollerblading bb. Ropes/challenge course cc. Sleeping dd. Swimming ee. Transportation z. Other* 2. Injury - Report all camper and staff injuries which result in death or which require resuscitation or admission to a hospital; camper injuries to the eye, neck or spine which require referral to a hospital or other facility for medical treatment; camper injuries where the victim sustains second or third degree burns to five percent or more of the body; camper injuries which involve bone fracture or dislocations and camper lacerations requiring sutures. Enter the information for questions 2A, 2B, and 2C in the table on front page. Up to FOUR injuries can be indicated per victim. A. Type of Injury: a. Bite d. Cut g. Internal (organ damage) j. Strain/Sprain b. Burn e. Dislocation h. Near Drowning k. Suffocation/Drowning c. Concussion f. Fracture i. Puncture z. Other* B. Area Injured: a. Abdomen e. Chest i. Foot m. Knee q. Shoulder b. Ankle f. Clavicle (collar bone) j. Hand/Finger n. Leg r. Spine c. Arm g. Eyes k. Head o. Neck s. Wrist d. Back h. `Face l. Hip p. Respiratory System z. Other * C. Cause of Injury: a. Bite from * c. Contact with heat or flame e. Falling/Stumbling g. Poisoned by * i. Submersion b. Collision with * d. Contact with sharp object f. Motor vehicle accident h. Struck by * z. Other * 3. Treatment - For each person providing treatment, indicate the location and type of treatment that person provided in the table below. Up to FOUR treatment providers may be indicated. Enter the information for questions 3A, 3B, 3C in the table on the opposite page. A. Who Provided Treatment? a. Dentist c. First Aider* e. Nurse Practitioner g. Physician’s Assistant i. Victim b. Emergency Medical Technician d. Licensed Practical Nurse f. Physician h. Registered Nurse z. Other* B. Where was treatment provided? a. At camp infirmary c. At site e. Doctor’s Office g. Emergency Room b. Admitted to Hospital d. Dentist’s Office f. Emergency Clinic z. Other* C. What Treatment was provided? a. Antibiotic f. Diagnostic k. Supportive (bedrest, observation, physical therapy) b. Antihistamine/Decongestant g. Epinephrine Administration l. Sutures*, Staples*, medical glue c. Anti-inflammatory/analgesic h. Gastrointestinal (antacid, laxative) (*Specify how many in table on front) d. Antiseptic i. z. Other* e. Cast/Splint j. Resuscitation