Form Doh-61h - Multiple Victim Injury Report Form - New York State Department Of Health
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1
2NEW YORK STATE DEPARTMENT OF HEALTH
Multiple Victim
Bureau of Community Environmental Health and Food Protection
Children’s Camp Program
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:
Female
Male
eHIPS Victim Number: _____________ (assigned by eHIPS)
Status:
Camper
Developmentally Disabled Camper
CIT/Jr. Counselor
Counselor
Other Staff* __________________
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 Number:_____________
Name of Patient: (Last, First, M.I.) ____________________________________________________________________________________
Home Address: ___________________________________________________________________________________________________
Name of Parent or Guardian (Last, First, M.I.)____________________________________________________________________________
Home Phone Number (
___ ) ________________________
**Shaded information is confidential
Age: _____
Sex:
Female
Male
Status:
Camper
Developmentally Disabled Camper
CIT/Jr. Counselor
Counselor
Other Staff* __________________
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
DOH-61h (2/03)
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