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DOH-61 (Fire) NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Community Environmental Health and Food Protection Children’s Camp Program Fire 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 to Local Health Department B. EVENT INFORMATION eHIPS Incident Number: (Note: eHIPS will assign when entered into system) Note: If a reportable injury occurred as a result of the fire, complete an Injury Report Form in addition to this form. Did an injury occur? R Yes R No Date of Incident Time of Occurrence (Military time) Where did the fire occur? Specify for locations marked with an asterisk: a. Aquatic area* e. Bathroom/shower i. Drama/stage area m. Open field/lawn* q. Recreational hall u. Tenting/campsite area b. Archery area f. Classroom j. Horseback area/trail n. Outdoor sports area r. Riflery area z. Other* c. Arts & crafts g. Cookout area k. Indoor sports area o Parking lot s. Ropes/challenge course d. Assembly area h. Dining area l. Kitchen area p. Playground t. Sleeping area C. 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: D. NARRATIVE- Do not include the full names of people involved with the incident. Use the first and last name initials or other similar code. Provide a description of the incident. Include details of the suspected cause of the fire, fire detection and fire department notification, personnel evacuation, assembly and accountability, as well as the camp’s compliance with Subpart 7-2 and the written plan. Information received by: Report reviewed by: