HomeMy WebLinkAboutRecreational Camper Injury Report Forms 07/17/2014 11:13 15083621614 CAMPWINGATE*KIRKLAND NHU� e��n�
� N�A.S�AC�US�Tx� DEPA.R'�MENT C)F �'UBLIC �EA�..,T�
CO�I�ITN�'�'� S.A►.�1I�`,A.'X'�ON l?����..A..�
REC�.E,A�'�'�ONAL �'A.1V.�P��t �N.T[�RY ��'O�'�` �'ORM
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j !n accorda�.ce�virh IVI.G.L. c. 111, §§3 and 127A and 105 CMR 430.000: Minimum Sanitation and Sa�cty Standards for
Recreationa!Caraaps for Children (State Sattitary Code Chapter IV), l05 CMR 430.�54 spec��cally requires that a,report
be catr��leted,�n a form}ax'escribed by the Massachuserts Department o£�ublic Health, �'or each fatality ar serious injury
f as a resul4 of whieh a camper or sts�'person is sent hame,or is brought to tYte ktospital or a physician's of�iee a�td�,vhere a
�c�sitive diagz►osis is�ade. 5uch injuries shall include,bsit shal!not necessarily be limited ta,those where��,�tu�ing U�r
� resuscitation is requircd��4C►eg IICC�PO�Ce�,pI�0 a�A��xS adfJ�ttteC�t0 tbe I�OSplta�.,A cp�y O�eaC�i 1ttJU1"}�t'@pOYt I�uSt�ie
� sent to tb�e Massaehusetts Depmrtment of Public Heaith within S�'VEN(71 days of the occu�re�aCe o�tb�e xqjury.
� PLEA.SE PROVTDE A, COM�RET-TENSIVE AND THOROUGN�SPONSE TO�V�RX QUESTTON.
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2. ,�hddcess' � t V`�,r� "�'�- City!Tuwn �f �'�r��// r l �� !
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3. Name of Camp Director: ��-~' �.'�'efephone: �}to� ,�'}���
�. Today's Aat�: ! � 6. Date of Lnnuy:���E' �� 7. Tizne o£T�njuzy: • ( �I)
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� 8. Dic3 the injury iaavolve a camper,sta£f person vr bvth: �J�
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9�. Abe of Gam er and/or Sta�'f Person: �d'� 9b. Gende 1V�a1e � Feznaie
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� t Q. Briefly describe the incident and subsequern i�,jury: t��ease slo not inetude�ersonsl ideatifvinQ inforxna�iq,�r}
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1 I. lf the i��ry occurced outdoors,�vhat were the�veather conditions at the time�f the incidenk?
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12. I�id the injury accux on the cann.pground? If not,specify the off-site location wheze the injury occurred.
(please describe tk�e exact locatian)
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t3. What la�dy part(s)were injured.
OX.Head/Skull Q2.Face Q3.Neck Oa.Arm � O5.Hand
06. Back 07.AbdOzne�t 08.Leg 09.A.c�de 1/ �Q.�ook
11. Other,please specify
a4. How did injuxy occu�t
01.Fatiizag V_02.Collision with person or object 03.St�'uck by anothet pe�'sotl Oz object
0�,Drowning or near drowning 05.Bite or Sting 06.Cut 07.Burn
Q$. Qtber,pE�ase 3peeify
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1S. Wk►ere was tt�.e iz�j+.u-ed�,erson treate ? 1� „.�,h�j/� ��'�^ �! 1 y��, ��
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� 02.Treatad ir►hos ital�mex�e�cy Rooxxr,Physic�an;'s OfFice
0�:. Treated�n camp�n�rrt�ary..__ . A �,,�f j
03. Adr►xitted to Hospital 04.Other}please specify ���`�'; (
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16. Was the cannper sent home as a result af the injury?
Yes No�,
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t?. Was ttaore tk►�one ca�;tp�r injured? Yes No • If Ycs,how many? — !
abtrse J ne tect? l�es Na �
1$, Did the injury invatve a1legEd �
19. What�hangcs were tniadc iti;thc cannp,its cnvironmcnt,or operation as a resutt of tk�xs ia�jux}r to prevent a revccutrence? , '
Please descxibe Speciftc changes made:
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Cl.� � sT� i'h tl� 1/II�CG�Y, S f?�'d'�`� ��
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PLEAS�'1V,f.AIL C1R FAJ�'C.��btP,E,R TNJU.RYR,�',F4RTS TO:
NtASSACHUSETTS D��'A.R7MENT OF PUBL�C HEALTM
BUREAU q�'�NVIRONMENTAL HEALTH �,
COMivIUNITY SANITATICEN PROGRAM .
250 WASk1�NGTON STREET-7th FLQOR
� IIOS'I'ON, MA 02108�4619
"tELEPEIONE(617}-624-5757
FA7C(G17)G24-5777
(Revised May 2008)
07/21/2014 02:49 15083621614 CAMPWINGATE*KIRK�AND PAGE 02/03
MASSA,CIT�TSE�"�'S DEPA,I�'��ENT OF P�L�C H�A.L'T'�i
C��M���'Y Sr�.Ni'�'A,'�`�ON �'RC)+G��,A,.�
' ��cz��.�rra�vA�, c.�m���� �N�Y r��Po�T �o�
In acc�rdar�ce�vith M.G.�..c. 1 i 1,§§ 3 at�d �Z7A and 105 CMR 43Q.Q00: Minimum 5an,itation and St�£ety Star►dards�or
Recreatior�al Camps£or Chi�drEn(State Sanztary Code Chapter N), X45 CMR 430.15A specifically requires that a regort
be cornpleted,o�;a form �ir�scribed bythe Massachusetts Department af Publzc Health,�'or each fatality or serious injury
' as a result o�'which a eamper or staff�erson is s�t�t hot�e,or is brouglat to the k�ospital or a physician's offiee and where a
positive di�gnosis is m.ade. Such injuries shall ir�clude, but st�ali not necessazily be limi#ed to,thvs� where suturiaxg or
resuscitation is required,bo�es are broken,or the child is admitted tQ the hospital.A,copy of e�eh injury xe�or#must be
sent to tb�e�vT�tssack�usetts Aepartmant o�'�'�ib�ic�ealth�vithin S���`e�I L1 days afthe accurre�;ee oithe it�jury.
Pi,BASE FROV�DE�.COMF�.E�fi.ENS�vE ANb'�HORQUG�RESPONSE TQ EVERY QUESTIO�i.
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� 1, Nar�ae of Canap: 4�V� �� v J�7 Y`fa..4.Q,��
2. rlddress: t"( � � /��' Cityi T'orvn ��� !`��
_\�U' l�l, �' 1'Y��iL. �U�'�rl�ILIr'1 d.Tel hor►e: �0 p� ` 1" '�
3: Natnz of Camp�u'ect�z r �P
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3. Today's�7aee: � D �� 6. Date of Injury:� 1 � �� 7. Ti�an.e of Injury:�(A�M�t
S. Did the injury in,volve a csmper,staff persoz�a�r both : ���r(�,�_
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9a. � A e of Cam er ar�d/or Staf£�'erson: � __. _ 9b, Gender: Mate��'ernale
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�� �0. Briafly describe the inciden�t and subsequetrt injury: (Pleuce o nQt iri ude personai identi�vins info�a ionl
'f��2�.d�i .�►.� 1 y- C'�lt/Y` �}�t�/I.r � t
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11. 1f tiie injury occurred outdoors,what were the weather canditions at the time of the incident?
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Ke�oct ID�Iumber
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07/2112014 02:49 15083621614 CAMPWINGATE�KIKKL�Nll rHut n���� '
�2. Did the injury occur on the cam.pS�aunct? If not,specify the off-site location Wh�re the injury occurred. `
(piease describe th exack tvcaei � ,
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13. Wk�.at body paTt(s}were iaajured:
01.Head/S1s.u�l
OZ.Face 43.Neak 04.r�..rm 45�E-Iand
08.Le 09.Ar.kle_r �.Q•Foot
06. Back �7.Abdoznen_ g
�7,_ Q�er,please speci'fy„��1�,�17 .
�4. How did injury occur?
01.k'alJ;tz►g�„_
02.Coll�sion with pe�son or object W 03.Savck by another person oz Qbject
OA.L��+wning or near drowrxia�g
O5.�ite or Sting -- 06.Cut �„^ 07.Bunn
O8. Qt�7;plEases�eci£� _ ,
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15. W�ere was the't.njused[serson treated7 E
�02,�"reated in haspital Emergency Room,�'1�►ysician's O£f ce
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01. Treated iz�camp infir�nary i
03. Adm+tted to Hospital 04•Ott�er,please specify
16. Vyas tl�e camper sent ome as a result of the injury?
Yes No,w_:___
o No V Z�Xes,hbw�'b;a�.y 7
�7. Was rno�e than ane camper injured. Ycs
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1$, pid the iajury�nVolve alleged abuse/neglect? Yes___„__No�_
a9, What c:h��ngcs were madc i,n the camp,its environment,or operation as a z'es«1t of this injtkry tn preverit a reocCurtence?
Please deseribe speci�ic ehanges made: � ! �!/ �C ��
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P,G.EASEIVX,�XL 4R FAX C.AM. PFR,f.NJURX R�'P4R7"S TD:
MASSACHUS�TTS DEF�IRTM�NT OF PU���L K��°►L� �
BUREAU OF J�t`3VIRONMEN"�"AL IIBALTH �
COMNIUNITY SANITATION 1'RnC�R.AM f
250 wAS�-l1NGTON STRE�T-7th FT�OOR ,
BOSTON,MA 02108-4b 19
'['ELI:PHON1�(b17}-624-5757 .
Ft�X (617)624��5777 f
(Rcvised May�008) � �
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