Free 45496.FH11 - Indiana

REPORT OF BURN INJURY REGISTRY
State Form 45496 (R2 / 1-07) DEPARTMENT OF HOMELAND SECURITY

INSTRUCTIONS: Please complete all spaces in this form.
Name of victim (last, first, middle initial) Address (number and street, city, state, and ZIP code) Date of injury (month, day, year) Area(s) of burn Time of injury Telephone number

This burn injury form must be filed within 72 hours to: DEPARTMENT OF HOMELAND SECURITY DIVISION OF FIRE AND BUILDING SAFETY 302 West Washington Street, Room E241 Indianapolis, Indiana 46204 Burn Injury Registry Hotline: 1-800-382-4628 Fax: (317) 233-8494
Date of birth (month, day, year) Sex

(

)

Male Female

A.M. P.M.

Severity of burn

1st

2nd

3rd

Percent of body

CAUSE OF BURN
Chemical Electrical Fireworks Other Specify

SPECIFY

SCALD
Coffee / Tea Radiator explosion Water Grease Other

THERMAL
Frost bite Radiation Steam Sunburn Other Gasoline Gasoline-trash Trailer explosion Trash explosion Vehicle House

FLAME
Bonfire Brush Brush-gasoline Commerical Gas explosion Other

Other, specify

OTHER
Aerosol Products Charocal Cigarette Cooking Utensil Curling Irons Friction Unknown Other, specify Yes No Did victim expire? Address where burn occured (number and street, city, state, and ZIP code) Name of reporting facility Address (number and street, city, state, and ZIP code) Attending physican How patient arrived Ambulance - ground Ambulance - air
Telephone number

Gas Grill Grill Hot Asphalt Hot Plate Hot Stove / Oven Iron Other

Lighter Fluid Lighter / Matches Lighting Nail Polish Road Friction Smoke Inhalation Other

County County

(

)

Private vehicle Public conveyance

Service date (month, day, year) _______________ Other: _________________________________

Transferred to _____________________ Transferred from __________________