Burn Injury Reporting Form
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1State of Connecticut
Department of Administrative Services
Division of Construction Services
Burn Injury Reporting Form
Office of Education and Data Management
To Report Burn Injuries
1. Immediately call the Local Fire Marshal in whose jurisdiction injury occurred.
2. Tell the Fire Marshal you are reporting a burn injury and give the following information:
Victim's name, address and date of birth
Area(s) of body injured
Apparent cause of burn injury
Address where burn injury occurred
Degree of burns and percent of body burned
Name and address of reporting facility
Date and time of injury
Injury severity
Attending physician
3. Complete the Burn Injury Reporting Form within 48 hours of the incident. This is a fillable‐form PDF. Please complete the form elec‐
tronically and email to: oedm@ct.gov with the subject line: Burn Injury Report. You may also print and mail the form to: Office of
Education and Data Management, DAS, 165 Capitol Avenue, Room 431, Hartford, CT 06106.
Check if incident has
Male
Victim’s Name_______________________________________ DOB_____________ Gender
received prior treatment
Female
(transfer patient)
Last, First, MI
mm/dd/yy
Victim’s Address_____________________________________________________________ Victim’s Phone ______________
Number, Street, City, State, Zip
Address Where Burn Occurred________________________________________________________ County
_____________
_
Number, Street, City State, Zip
1st 3rd
Date of Injury_____________ Time of Injury_______hours Percent Burned____% Degree(s) of Burn(s)
2nd
Inhalation
Burn
mm/dd/yy
military time
Area(s) of Body Injured (Check all that apply)
Injury Severity (Check appropriate box)
1. Moderate
1.
Face, Head
6.
Leg
(treated and released)
2. Serious
2.
Neck, Shoulder
7.
Foot
(hospitalized)
3.
3.
Chest, Abdomen
8.
Arm
Life Threatening
(death is imminent and/or probable)
4.
Back, Buttocks
9.
Hand
4.
Dead on Arrival
5.
Groin, Genitals
10.
Internal
(including trachea and larynx)
Apparent Cause of Burn Injury (Check appropriate box)
1.
Chemical
—Contact or exposure to reactive, caustic, corrosive or irritating substance
2.
Contact with Hot Object
—Woodstove, stovepipe, furnace, iron, steampipe, exhaust pipe, etc.
3.
Cooking
—Stove, oven, hotplate, barbecue, hot grease
4.
Electrical
—Electrocution, electrical equipment and flashburns
5.
Explosive
—Gun powder, TNT, dynamite
6.
Fireworks
—Sparklers, firecrackers, rockets, smoke bombs, etc.
7.
Flammable Liquids
—Ignition of flammable/combustible liquids such as gasoline, kerosene, diesel fuel, jet fuel, lighter fluid, etc.
8.
Gas/Vapor Explosion
—Ignition of flammable gases or the explosion of flammable liquid vapors
9.
Hot Liquid
—Hot water, coffee, tea, hot food, hot tar, melted plastic, etc.
10.
Other Open Flame
—Welding, matches, lighter, torch, etc.
11.
Outside Fires
—Grass and brush, forest, bonfires, dump, trash and refuse fires, etc.
12.
Radiation
—Burns caused by contact or exposure to any radioactive materials
13.
Steam
—Caused by escaping steam from radiators, boilers, pipes, etc.
14.
Structure Fire
—Any uncontained burning within a structure, including smoking accidents, trash fires, etc.
15.
Sunburn
—Exposure to ultraviolet light, including sun lamps
16.
Vehicle Fire
—Car, truck, plane, boat, tractor, lawnmower, etc., carburetor and engine fires, etc.
Name of Reporting Facility________________________________________________________________ Date of Report_____________
mm/dd/yy
Address of Reporting Facility________________________________________________________________________________________
Number, Street, City, State, Zip
Name of Attending Physician____________________________ Name of Person Completing Report______________________________
Last, First, MI
Last, First, MI
Office of Education and Data Management, Department of Administrative Services, 165 Capitol Avenue, Room 431, Hartford, CT 06106
phone 860.713.5522 ●
fax 860.713.7426
Authority of CGS 19a‐510a DPS‐330 Rev 1/15
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