Nys Ofpc Burn Injury Report
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1
2New York State Division of Homeland Security and Emergency Services
Office of Fire Prevention and Control
NYS OFPC Burn Injury Report
(File within 72 hours)
If hardcopy PLEASE print legibly
MUST be filed in accordance with NYS Penal Law Section265.26
VICTIM'S NAME (Last, First, M.I.):
SEX:
MALE
FEMALE
VICTIM’S ADDRESS (Number, Street, Apt.):
DATE OF BIRTH:
CITY, TOWN, POST OFFICE:
STATE:
ZIP CODE:
TELEPHONE NUMBER
ADDRESS WHERE BURN OCCURRED (Number, Street, Apt.):
CITY, TOWN, POST OFFICE:
STATE:
ZIP CODE:
COUNTY
DATE OF INJURY:
PERCENT BURNED:
AREA OF BODY:
%
Face/Head
Leg
Neck/Shoulder
Foot
TIME OF INJURY:
DEGREE OF BURN:
Chest/Abdomen
Arm
st
rd
HRS.
1
3
Back/ Buttocks
Hand
nd
2
Inhalation
Groin/Genitals
Internal
(24 Hour Clock)
APPARENT CAUSE OF INJURY:
INJURY SEVERITY:
REPORTING FACILITY:
NAME OF ATTENDING PHYSICIAN:
ADDRESS OF REPORTING FACILITY (Number, Street, Apt.):
CITY, TOWN, POST OFFICE:
STATE:
ZIP CODE:
DATE OF REPORT:
PERSON FILLING OUT REPORT:
NYS DOH PFI #:
CHECK THE BOX IF:
INJURY RECEIVED PRIOR TREATMENT
THIS IS A REVISED REPORT
CLICK TO SUBMIT TO OFPC BY EMAIL
CLICK TO PRINT FORM FOR FAX OR YOUR RECORDS
OFPC OFFICIAL USE ONLY:
BURN INCIDENT #: ______________ IMS DATE: ______________
OPERATOR: _____________
DHSES OFPC Burn Injury Report
Authority: NYS Penal Law Section 265.26
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