Loading...
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 a , 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. i , a + j/r/l (��� �ar�,��� i. 1Varne of Camp: � 2. ,�hddcess' � t V`�,r� "�'�- City!Tuwn �f �'�r��// r l �� ! � � �v�n� ei ��Ug / 3. Name of Camp Director: ��-~' �.'�'efephone: �}to� ,�'}��� �. Today's Aat�: ! � 6. Date of Lnnuy:���E' �� 7. Tizne o£T�njuzy: • ( �I) � � ; � � 8. Dic3 the injury iaavolve a camper,sta£f person vr bvth: �J� ; r� 9�. Abe of Gam er and/or Sta�'f Person: �d'� 9b. Gende 1V�a1e � Feznaie � � � j � t Q. Briefly describe the incident and subsequern i�,jury: t��ease slo not inetude�ersonsl ideatifvinQ inforxna�iq,�r} V� ��` G7l� I� Q� /�-,� r��� °�.•� Yt�ID�'-2�eC � ��i �� �� � �►�s�(, �.�s r�n �.-r , s Gl�s-et� � S�i� s � ' �U'��, � �t S G�Y�'. ..... ,r�� h�— �`� P� ; �� �, � 1���,, �.� ��C � ��.1���. W� �Sh S'v�t �. 1� � Y�.ar�,n a �..� __�,�,� -� 14� t�` n��etr�- � k . Y'� �� � �1/�i- . 1 I. lf the i��ry occurced outdoors,�vhat were the�veather conditions at the time�f the incidenk? ��� Y�� —.�� .. , ._.....,......_ Iiepa•t In Numl��., �U �� {CpitttRUGC�Ovgr� ilnts:nal t:�s t)nl}l , - . . l'HIrIrWlIYVIHIC'^hl(Ct�LHI`IL � nu� `�`�� �`� ��i CI(!1!/Lll14 11:13 lOYJt53bL1014 f 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) �s — -�- 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$. Qtber,pE�ase 3peeify ll�� �i 1S. Wk►ere was tt�.e iz�j+.u-ed�,erson treate ? 1� „.�,h�j/� ��'�^ �! 1 y��, �� l.�[ v v r.�1 3�:....�.,. �� � 02.Treatad ir►hos ital�mex�e�cy Rooxxr,Physic�an;'s OfFice 0�:. Treated�n camp�n�rrt�ary..__ . A �,,�f j 03. Adr►xitted to Hospital 04.Other}please specify ���`�'; ( V 16. Was the cannper sent home as a result af the injury? Yes No�, i t?. Was ttaore tk►�one ca�;tp�r injured? Yes No • If Ycs,how many? — ! abtrse J ne tect? l�es Na � 1$, 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: �L Cl.� � sT� i'h tl� 1/II�CG�Y, S f?�'d'�`� �� _,._ � �r _ _ . - - - _ _- _ _ - . _ --- - - � . ._ .._ � 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. , K � 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 I p� �� f� 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(�,�_ T 9a. � A e of Cam er ar�d/or Staf£�'erson: � __. _ 9b, Gender: Mate��'ernale B P �� �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 � � �Q��..�/�' � .. �� ���~� 5�������.. } 1� G�-!V , 1 C.Q, ,Ll1�..^ ,�G� �7v�J (M�-� '��'�, ,. '��tJL��v .� ��'� _ �.�. � _ �� � �o c� �',� � '�''�' X�-Yr . � ; � �� ,-�✓�i � ���rs s��rrl�r a � � 11. 1f tiie injury occurred outdoors,what were the weather canditions at the time of the incident? � ,,�'�" Ke�oct ID�Iumber �� � (continued over} .. . �,fl�cma�use oo�y1 f 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 � , � �..�..�. . 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£� _ , ^�. --- � 15. W�ere was the't.njused[serson treated7 E �02,�"reated in haspital Emergency Room,�'1�►ysician's O£f ce � R 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 � t 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 �� �16�, ��� �/� �'�i _ _ s, P`� ` vU�e�l rr �t 1-e � ��.- 5�� :� �-� 1� , ---� - �� � � 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) � � i