Form Doh-61h - Multiple Victim Injury Report Form - New York State Department Of Health Page 2
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1
2Instructions:
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
o. Free period
y.
Riflery
z.
Other*
e.
Boating/Canoeing
p. Games – organized*
aa. Rollerskating/rollerblading
f.
Chores
q. Gymnastics
bb. Ropes/challenge course
g.
Classroom instruction
r. High adventure activity
cc. Sleeping
h.
Cooking
s. Hiking
dd. Swimming
i.
Court/Field sports*
t. Horseback riding
ee. Transportation
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. Psychotropics
z. Other*
e. Cast/Splint
j. Resuscitation
DOH-61h (2/03)
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