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Home My WebLink AboutRecreational Camp Injury Report Forms ac�c��oec�o � Massac�tusetts Department of Pubiic Health , Community Sanitation Program AU� 2 0 2015 ' Recreatianal Camp lnjury Repor# Fvrm HEALTH DEPT. � in accordance with M.G.L. c. 111, §§ 3 and 127A and 105 CMR 430.000: Minimum Sanitatian and Safety Standards for Recreational , Camps for Children {State Sanitary Code Chapter !V), 105 CMR 430.154 sPecificaliy requires that a report be completed, on a form prescribed by the Massachusetts Department of Public Health, for each fatality or serious injury as a result of which a camper or ' staff person is sent home, or is broughi to the hospitai or a physician's office and where a positive diagnosis is made, Such injuries shall include, kaut shall not necessarily bE limited to,#hose where suturing or resuscitation is required, bones are broken,or the child � is admitted to tfie hospital. A copy of each lnjury report must be senfi to the Massachusetts Departmen# of Public Health within � SEVEN (7)days of the accurrence of the injury. ; PLEASE PRt3VIDE A COMPREN�NSIVE AND TNOROUGH RESPflNSE Tt}EVERY QUESTION. � � �1. Nameo#Camp: � L�i:IC � �i(��1CSfl�• ; 2. Street Address(please indicatt the camp's in-session,physical address): F �� t��,;��. R��k � t - � City/Town: �d � (['�I�JT`n t'Of �'" Zip Code: C�a�(��S� 3. Name of Camp Director, �"� ��V "� �� I�t1 Y}�i'lS'tc t(1 4.TeFephone: �U t� �[��' ��_1 6 5. �tame of Person Completing Form: 1�L�#��i.. �ts�{�4{� �� 5. Today's�ate: � �,�,��„__,, 7'. Da#e of injury:��,�_____ 8.Tirne of injury: lL7 �AM �M 9. Enter the nurrsber of campers and staff whv were injured: ,�Camper_Staff inem6er Note:Fi!!o�rt a separate{csrrn fvr each injurer!person '' i 1�, a)Age of person whose injury is described on this form:�_ b}Gender: �M ❑ F , 11. Where did#he injury occur? ❑ On camp property_ Ld Off camp property 12, Please specify the type ofi facility where the injury occurred: 0 Athletic or recreational facility ❑ Pa�� ❑ Dorm or sleeping quarters ❑ Other watsr body(nat pool} ❑ fV�otor vehicle L� �ther,p4ease specify: (��,�f-�-,� �"�� 13. What was the incident outc�me?Please check a11 that appiy: � injury tJ 111ness ❑ Death . 14. Explain in detail how the injury accurred(e.g,what type of activity was the injured person engaged in when the injury occurred) and describe the nature af the injury. Do not inciude names or other personat identifying infarmation regarding the injured persan or otfier involved parties. � �� _ �j (l�A.e.S S Gt:�s �� G� r,z� � ' �� , �" Ca . � �'� tat �-- d"l�� ... r� '�'n �„> �' 'L� � � Gl �,n s � ��e� t� .� � �c - �.,, . - ,s � � a �s : - .d� �-�--~-I�� 'lJ� 1��. ... � �. Y � . � 1 . . . +"f� � �� .. ' ��Q. J�i �4 . , � Rsport ID#i mternal use onl �ll !� (cantinued aver) c� v�:�`�.�-.s� . Cross-reference�J(internol use anlvl: - - RPv+sPd nrrnhw��ma i ..�-.,...�,.�w..,...._,,,..-.�,,..,...--� ,..,.._�.�.._..__- ... ..., t 15� Type�of inj�ry..Please ch�ck afi that app ; � � �r; _ L�'��F,��d`,:ak3��+or n�giect Allergic reaction ❑ Bite ar sting ❑ Bruise or contusion ❑ Burn � ❑ Cancussion ❑ Cut or(aceratEon ❑ Drowning � �v ; i � j.� i S s :r ,s ' �.,...� Heat or cold(e.g., hea# ' �'Q" '�racture or dislocatian � exhaustion, hypothermia) � Muscle strain, ❑ Near drowning Psychoiogical or mental Viral or bacterial � health issue � Undetermined � infection L3 Other,please specify: 16. What body part(s)were injured7 Please check all#hat apply: �Head,neck,and/or face ❑ Torso, please specify: . ❑ Abdomen ❑ Back [�Chest ❑ Hip ❑ Upper extremity,please specify: ' ❑ Arm ❑ Fingers ❑ Nand ❑ Shoulder ❑ Wrist -- -L�-1aw��Extreuiit�,,Ptease-specifv� ------ -- ---- — _ ._---- ---- _ _ __-- r— - - _ ( ❑ Ankle ❑ Foot ❑ ��e ❑ Legs ❑ Toes j ❑ �internai � ❑ Other,please specify: � � 17. Where was the persnn treated7 Pfease check ati that apply: a },�� Admitted to hospital �Off-site medical facility{e.g.,emergency room, � On-site medical facility I physician's or dentist's office) (e.g.,clinic or infirmary} j ❑ Other,please specify:.' 18, Was injured person sent home? ❑ Yes L! No 19. Did your camp change equipment,policies,or procedures as a result of this incident? L� Yes ❑ No z0. If yes, please check all that apply; � Ac#ivity removed or � Changes to equipment �New safety procedures [] Safety education updated farbidden implernented implemented ❑ Venue changed or altered [j Other,please specify: 21. Brieffy explain changes�mplemented as a result of this incident. IF no changes we{�je made, please explain why not. I '.S Q� Ci t�� __ _____--- , ___ - -- ---- - - _ ____ -- -- -- _ _---- —�--- : _ --- , t v ��- � , r�. C".t��(1P�" (��" CU��C��'" i�� `�L'- �'�� C�S C� a,,�w�r'� �c.� � 1�� r;,�., PLEASE MAIL, FAX,OR EMAIL CAMP INIURY REPORTS T0: MA�SACNUSE�S DEPARTMENT OF PUBLIC HEALTH � BUREAU Of ENVIRQNMENTAL HEALTH CQMMUNI7Y SANITATIQN PROGRAM 250 WA5NINGTON STREET-7th FLOOR � gOSTON,MA 0210$-4619 TELEPHONE(617}-6Z4-5757 FAX(617)624-5777 celestine.payne@state.ma.us Revised October 2014 � ._._.,�.�.. e � 4 _ � � L MasSachusetts Department of Publi� Hea#fih � � f �.�� ► �i i'�� s Community Sanitatic�n program � :, z Recreational Camp lnjury Report Form y � ' �..._.�__ e �_�_�_�__-__° a_---� In accardance with M,G.L.c. 111, §§3 and 127A and 1�5 CMR�430.000: Minimum Sanitation and Safety Standards for Retreational Camps for Children �State Sanitary Code Chapter tV), 105 CMR 43Q.154 specifical3y requires that a repart be compteted, on a form , prescribed by the Massachusetts Department of Public Neafth, for each fatality or seriaus injury as a result of which a camper or staf#persan is sent home, or is brought to the hospita! or a physician's office and where a positive diagnosis is made. Such injuries shal!include, but shall not necessarily be Cimited to,those where suturing or resuscitatian is required, bones are broken,or the child is admitted ta the hospital. A copy af each injury report must be sent to the Massachuset#s Department of Public Heal#h within SEVEN (7}days of the occurrence af the injury. PLEAS�P'ROVIDE A Ct7MPREHENSNE AND THOROUGH RESFONSE TD EVERY QUESTtON. t �� / i �Q 1. Nameo#Camp: ��t'ilC?. �vt("1��.� I'Li��1GY11�` � 2. Street Address(please indicate the camp's in=session,physical address�: �7 � ��1�� Rc�c.1C � City/Town: i 1" � Zip Code: 't��i�Q�.J� 3. Name of Camp ector: Y'v t1��,1 ''' �� l��15'�c t(1 4.Telephone-: S�p ��` ��c� S. Name of Persnn Cnmpleting Form: �('�.{��. �l L�(f'_ l� 6. Today's Date: ��,�,�� 7. Date afi injury:_�'�Z�_ 8.Tirne of injury: �� t"AM I� PM 9. Enter the number of campers and staff who were injured: _Gamper�Staff member No#e:Filf out a separate�arm for each injured person � 10, a)Age of person whose injury is described on this form:� bj Gender: ❑ M � F 11, Where did the injury occur? On camp property 0 Off camp property 12. Please specify the type of facility where the injury occurred: ❑ Ath}etic or recreational faci{ity ❑ Pool ❑ Dorm or sleeping quarters ❑ Other water body(not pool) ❑ Motor vehicle �Other,please specify; �� D ��..e 13. What was incident autcome?Please check all that apply: ' tnjury ❑ Iliness ❑ Death - � � 14. Explain in detail how the injury occurre�i (e.g.what type of activity was the injured person engaged in when the injury occurred} and describe the nature of the injury. Do not lnclude names or other personal identifying informatian rega�ding the injur�d person ar other involved parties. !'� _ � � ! ��.. ��- � � ��,�. -�,1� ��is-�� h�-- �.��!� a ��.� � � ��- , � �-- � ��- � �,� � -s� ►� -� � �� , , I _ � � ' �. �.0 e, +3{> c ' ; �..e �. j , t �� _ - � l e� � � �" �s � � � � � �� C � � i f 1 , , � Report ID#(interncrl use on(yJ:� �� (continued over) � - r n �# ' te 1 n . - - Revised C7ctaber 2014 , C ro s s r e fi e e c e (r n r n a u s e o I Y)� 15. Type of injury.Please check all that apply, ❑ Alleg.ed abuse or neglect ❑ Allergic react'ron � Bite or sting ❑ Bruise or contuslon ❑ Burn ❑ Concussion � Cut or laceration ❑ Drowning ❑ Fracture or dislocation ❑ �eat or cold(e.g„heat �.uscle strai� ❑ Near drowning exhaustion, hypothermia) Psychological or mental Viral or bacteria! � health issue d ��determined � infertion ❑ Other,please specify: 16. What body part(s)were injured?Ptease check all that apply: . ❑ Head,neck,and/ar face ❑ Torso,please specify: ❑ Abdomen ❑ Back ❑ Chest ❑ Hip ❑ Upper extremity,please specifiy: , ❑ Arm ❑ Fingers ❑ Hand ❑ Shoulder ❑ Wrist _ ❑ Lower extremity, ease specify:__ — _- - -- ___—--- -- _ _ — __-- ----- Ankle ❑ Faot ❑ Knee ❑ Legs ❑ Taes ❑ Internai ❑ Qther,please specify: 17. Where was the person treated?Please check all that apply: ❑ Admitted to hospifial ��'site.medical facility(e.g.,emergency room, �-site medical facility physician's or dentist's office) . �e.g.,clinic or infirmary) ❑ Other,please specify: � 18. Was injured person sent home? Yes ❑ No 29. Did your camp change equipment, policies, or procedures as a result of this.incident? ❑ Yes No + 2fl. If yes, please check al1 that apply: � Activity remaved or � Changes to equipment � New sa�ety procedures �afety education updated farbidden implemented implemented Q Venue changed or altered ❑ Other,please specify: 21. Brie ly explain changes implemented as a result of this incident. If no changes were made, please explain why not. �.. ��- � -e� t� ` r' c �os�� - �rL ti�- . ---- ---- --- ---- __T _ _ _ �- __ - -- - �---__ � - — _— __ 2 (J�5 • Sc> . � t�, ( -�. e_. ��` S , � ,ri �t`S PLEASE MAII, FAX,OR EMAIL CAMP INJURY REPORTS T0: MASSACNUSETfS DEPARTMEN7 OF PUBIIC HEAtTH BUKEAU OF ENVIRONMEIVTAL HEALTH . COMMUNITY SANITATION PROGRANI 250 WASHINGTON STREET-7.th FLOOR BQSTON, MA 0210&4619 T�LEPHONE(617)-62�-5757 FAX(617)6245777 ce I e sti ne.pa yne @ sta te,m a.u s Revised October 2014 f_ ��1 1:�... "._.. _J Massachusetts Departrnent of PubSic Health �� ? 7 2�i5 Community Sani#ation Program �..! f�.l..T3.i �..�„' � Ftecr�ational Camp Inju�y Report Form � In accordance with M.G.L. e. 111, §§ 3 and 127A and 105 CMR 430.000: Minimum Sanitation and 5afety Standards For Reereatfonai Camps for Ch.ildren (State Sanitary Code Chapter IV), 1Q5 CMR 430,154 specifica(ly requires that a•report be carnpleted, qn a �arm. prescribed by the Massachusetts Department of Public Nealth, for each fatality or serious injury as a �esult of which a c�mper or staff person is sent hom�, car is browght to the hospital or a physician's of#ice and where a positive diagnc�sis is made. Su�h injuries shal)include, kaut shaU not necessarily be limited to,thosE wher'e suturing or resuscitation 1s required,bones are broken,or the chrld is admitted to the hospital. A copy of each injury report must be ssnt to the Massachusetts Depat#rrienY of Publ'tc Neaith �vithin 5EVEN{7)days o#the accurrer�ce aFthe tnjury. PLfASE PR(3V1DE A COMPREH£IVSiVE AND THQROUGH RESPtiNS�TO EVERY q1JE5'f101�. . � �Q 1. NameofCamp: ��iwlT �cr��f�C.fl�✓` z. Street Address(please indicate the c�mp's in-session,physical address); �G 1��,��.. Rc�c.� �� ____ �1 -^��c� City�'T'own: �.' (t'f1C'��i'1 �Qr � Zip Cade: r,��D / .J 3. Name of Camp Director: .� i`��V "� W, �1, v�r'1�"i'C t (l 4,fieleph�ne: s�t� ' �� ' ..'�� 5. Name of Person Completing Form: �G''..-�e C� ��[�� I i � � �� ,.,�,,r 5, Today's Date: _s;�� 7. Date of injury:---�-��-�-- 8.Time of In}ury:�� .i.�'AM ❑ PN1 9. Enter the number of carnpers and staff who were injured: ��amper��taf#member Note:��11 aut a separate farm for each injured person 10. a)�ge of persan ti,vhose injury is described on this form:�T b�6ender. ❑ M L1c( � 11. Where did the injury occur? LEa' On camp property ❑ Off camp prt�perty 12. Piease specify the type of facility where the injury occurred. Lid' Athletic or recreational facility � Pooi ❑ Qorm qr sieeping quarters ❑ Other water body{nat poolj ❑ Motor vehicle ❑ ather,please specify: � 13, What was#he ineident outcome?Please check all#hat apply: �. �njury ❑ Illness ❑ Death ___ __ __ ; 14. Explain in detail how the injury occurred (e.g.what type of activity was the in}ured person engaged in when the injury.occurrPd) and describe the nature of the injury.Do not inciude names or ottier persana(iden#ifying informativ�r regarding ti�e finjured person or other involved parties. , t_ ( i ��`i,,+�C�� (��,�a�� C) �. ' r �.�. ` <^t1 ��.�' tt� £?1`� �V)c � . J��. ; ,_.� i ^ ,� i� i # 1 Q-Y°a� � ', � � � � ��. ��-i�l t",� '� � ' ` (� � � �7• � ar �" _ >�" "-�t:\ i � • M_ �„�i�#'_:t;u � � � ��. '{;' _ ! . - � �, � � ar��r_- �1�� n� �r��- � `��n _ ��i� •. �vt�.�- c� �r�( �l t`•'.5�� . �'' � � � � 'ud f}C�'y�'"LU�i..� ��.�'1 {"�'.T#"'{:�c2e� ��t7 f�°'.�r7�� . �_.�. _ j � � � � . { Report ID#{internal use anly):�� (T'(7 (�o�tinued nver) , s'•..,�-...„F...,�...-,, t7 IL,�.,��.�;!�.�.. r..,f,�t. . �,_. .. �.... , . ..., , 15. Type of injury.Please check aN that apply: [I Alleged abus.e or neglect CI Allergic reaction ❑ Bite or sting ❑ Bruise or contusion ❑ g�rn ❑ Concussion C7 Cut or laceration ❑ Dr�wning Heat or cold(e,g., heat Fracture o�dislocation � QX�austiart, hypothermia) � Muscle strain ❑ Near drowning Psycho{ogical or mental Viral or bacteria) � health issue ❑ Undetermined � ��fec#ion �. C� Other,P�ease specify: 16. What body part(s}were injured�Piease check all that apply: . � ❑ Nead,neck,and/ar face � (� Torsa,Please specify: i � Abdomen ❑ Back L� Chest ❑ Hip ' � ❑ Upper e�rtremitjr,please specify: , ' ❑ Arm ❑ Fingers 0 Hand ❑ Shoulder ❑ Wrist i _ ` _ ' ,�}ease s�e�i#�_ ____ __ __ _ ' __ -- _ . ____ ___ — _ _ ❑ Ankle ❑ Foo# ❑ Knee egs ❑ Toes _ ❑ intemal ❑ O#her,please specify; 17. Where was the person treated7 Please check all that apply: Off-site medical fac.ility{e.g_,emergency�oom, � On-site medical#acility �drrmitted to hos ital ❑ � physician's or dentist's office) (e:g.,ciinic or infirmary) ❑ Other,please specify: � 18. Was is�jured pe.rson sent home? �r res ❑ No ��y� �`��'��-�� 19. Did your camp c:hange equipment, palicies,or procedures as.a result of this incident? ❑ Yes No 20. If yes, please check ail that apply: � Activity removed or � Changes to equipmenk � New safery procedures (� �a€ety education updated forbidden irnplementad �mplemented ❑ Venue changed ar altered � Other,please specify: 21, Briefly explain changes imple ented as a result o�this incident. If no changes were made, please explain why not. j � ti �� PIEASE MA1L, FAX;OR EMAfL CAMP INJURY REPQRTS T0: MASSACHUSET"i'S DEPARTMENT OF PllBLIC H£A1.TH ' f BUREAU OF ENVIR�IVMENTAL HEALTH COMMUNITY SANITATIflN PROGRAM 250 WASHINGl'QN STREET-7th FLOOR BQSTON, MA 02108-4619 TELEPHONE{617j-624�5757 �AX(617)6245777 �elestine.payne@state.ma.us ' Revised October Zp14