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Home My WebLink AboutRecreational Camper Injury Report Forms 614 CAMPWINGATE�KIRKLAND PAGE 02/03 � 07124/2613 02:50 15083621 , 1V�.A►SSA,C�USE'��'S DEPA,l:2.�'MEritx U�' �U�3L�C H�,�►.L�'�g,__ �.ry.�.. ' CO�ITNI'X'X S.ANT�'.A,'�'�O�T �"�t.�GF� ¢,� � � � �J�� , �CR�A,'�'�ONAL C,A.MPE�t. ��tJU�t.X �PO�'�' �' �' � '� �=:ti�1=..��g. F1��. �n a�cordance w�th M.G.L. c. t�9., §§3 and 127A and �OS CMR 43�.000:�i�nizx�;utla Sa»itation and Safety Standards for � Recreatior�a�Ca�x►:ps for Chitdrett(State Sa�it�xy Code Cktapter IV), 105 Ctv1�t 43p_1S4 speeifically rec�uires ttaat a repart f b�eompleted,on a form prescribed by tbe Massachusctts�7epartmeilt o��'ublic k�c�.lt1�,for each fatdlity oe 5eriou5 iz�juxy as a result o�wk�xch a ca�pex qc sta£�person is sent home,o:r is b�ougk�t to the�ospitel or a physicia�a's o�ce and where a positive diap,�os�s is made. $uch�njucies st�all include,bttt sha11 not necessarily be li�ited to,those whe�e sutu��n�or resuse�tation is required,bott�s are brokett,or the ck�i�d is admitted to t�e�ospital.A eopy of eacb�iqjuay r�port must be r sen#to t6e Massachusetts Dep�rtment of�ubi�c Healt�t wxtb�n�SEVEIv days of the occuxre�tce vf the iajury. , PLEASE��t,OVZD�A COM�4'�F-�.NS�V�ANp?�t0�i.0UGH RESPON�E TO EVERY QUESTION. � � � �r�j� 1�. Namc of Camp: + �( f��'J��► �t �'Y 2. A�dress: � ,�� w �CitylTowt� � � p /� G� i Na �of Cam Dixeccor. �Ui.� � �1 L��.•'��n J[�-1�4.Teleghone: ��U �Cl��_! �� I � � �. m � -- , y, i r 5. �'oda 's Date: � ��1 !� 6. Date of Injury:� �� 7. Time of injury:�� Y � $. Did the iz�jnry ir�volve�camper,staff parsan oc both: �.�t �r t � 9a. ,A.ge of Camper andlar Smf�k'exsa�:( / 9b. Gcr,dcr: �aa� fierattic --- 10. Briefly dcscribe r.�e incident and subsequen.t�njury: lea e do not inc�ude ersonal identifvin i forrn�ti �rn �r G�S' �. �' �S�-� �� . i �`� ��" r� �h� �.� � I �� , � � 1`� �� 'V�' �11� �5� , : Y` �� Dr�l I� I � - _.. �,�, , � ��,�"r�� , � _.�- - 1 i. lf the injury occurred butdoors,what were the�veather conditipns at the tintae o�tha�ncident? ; _ 1-,�.� �, � - ., � ; Rcport)n Numbcr� � J �� (contin;ued over) � jtoiemBl lise pnly) .. T 07124f2013 02:50 15083621614 CAMP4JINGATE�KIRKLAND 12. Uid the injury occur qn the campgrUund? tf not,�p�cify t}�e off-site location wFicre the injury occurred, PAGE 03/03 (p(ease desccibe the exact location) �51��e� ��v��" �3. Whah bc�dy part(s)were injured: 0!.Head/Skull Oz.Face _ 03.Neck Od.Mm Q5.�-��d � ` � �� 06. $ack 07.Abdt�men 0$. �,e8 09.Ankle�-- 10.Foot � �1. Okher,please specify .._—.� �4. Haw did i�jury occur? �7 ,I�'l� �� . 4i• �al�ia��w____. 02,Cvl�isio�with person or objeck� 03.Struck by another person or objeet � 0�.Drowning oe near drotivnAng 03.$ite or Stin Q6..Cut p7,gi�� .� _�__. _ �8.-��P�ifY ._.."_. 15= bVhere was the i�jured person treated? U1.. Tceated in`camp in�rmary `1/ pZ,Treated in�hospital Emergency Room, k'hysician's Office � 03. qdrpitted to Hospital�p�t,ptk�eF,pl�ase Specify_ 16. tiVas the camper s�nt hom.e as a re5ult ofthe injury? `,�es No V �7, Was more tlaan or�campzr in,�c�red? Yes No� If Ycs,how many? 18, Did the injuty involve alleged abuse/naglect? Yes o � N 19. Wl�at charta�s�.vere m�de un the eamp,ics envfronmcnt,or operation as a result of tk�is i,njury to prevent a reoccucxenee? Please describe speci�ic c�anges made� .��'�, _ ��f� � _ _- __ _ , �� ,� _�_l__ ��__ _ _ ,� ,�,��j_ � ,�1 ------- -.� P'LEASE MAIL OR F.�CfIMPER I1�rJU.RY.R,&',PO.1Z.7'S TO: M�ASSACHUSE7TS�7EPAitTM�NT Ok'PUB�,IC HE,A,(,TH BtJRFA,U OF ENVIFt01'Ji�IEN.TAL HEALTH C:OMv(UNlTY SAN17'ATION PRQGR.�tivi 250 tiVASH1NG'1'ON STRFf;T-7th PLC7�R� �os'ro�, n�� ozzos�a�� 'Cf;�.4�t'FtOiVE(617}-G24-�7�7 I��X(617}�2��-5777 (Cteti�isEti Iv(3y 20Q3) [ f ''� � ETTS DEPARTMENT OF PUBLIC HEALT�``� � MASSACHUS � � COMMUl�TITY SANITATION PROGRAM ��- '� : � ,� �,> RECREATIONAL CAMPER INJURY REPORT �0�,�� - . ay,� , � � � � -�� : ��"� In accordance with M.G.L.c. 1 l l, §§3 and 127A and 105 CMR 430.000:Minimum Sanitation and S�afet}� dards for � ter 105 CMR 430.154 specifically re� ' es that a report Recreational Camps for Children(State Sanitary Code Chap IV), ; 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 brought to the hospital or a physician's office and where a positive diagnosis is made. Such injuries shall inctude,but shall not necessarily be limited to,those where suturing or resuscitation is required,bones are broken,or the child is admitted to the hospital.A copy of each injury report must be sent to the Massachusetts Department of Public Health within SEVEN days of the occurrence of the injury. PLEASE PROVIDE A COMPREHENSNE AND THOROUGH RESPONSE TO EVERY QUESTION. � ofc� : i^ � �r�� ' 1. Name p �,/�� 2. Address: �!?/ City/Town ��'�'��W �'l�� " "� _ ��i �� 9� r:U�'� a ��'?u'7�-�ruG�l��L�� 4.Telephone: 3. Name of Camp Duecto r � � •�� 6. Date of Injury: �'�`�'' �� 7. Time of Injury: �'✓�' (A�� Toda s Date. `� 5. � y . ,' Did the iri involve a camper,staffperson or both: �'�� ' `*� 8. J�Y 9a. A e of Camper and/or Staff Person: /c� 9b. Gender: Male Female g =-,r -�= .�. !:�=�=?�� ;:��+�:; �i_: 10. Briefly describe the incident and subsequent injury: (Please do not include nersonal identifvin�information) � � G�.e3�`�_ a�.�v' ��r�r� �/�,� ��c� , ' ��'��-n� w �. �,, ,, � �e�,/ , C' ,��'� }�� /Y�-��r�1'` : , �:' ��-' � , �'��1/rn�Y'�l �ac rn r v�a.s 1a �� -r � -l� w>�h � Q1 h��` ��r�- :�^s ,�r,Y�C SHL ;}� �"h� � � s�d� � �� n e� rC i� vr�-� � � �(, ,r ��ef � h.� � , :r. .�"s� ?h.� n��r�,� �� .�r� 1�/��.� S �� ,n �bJ�,t� ' lt� brU� � �t � , , . � c� `�R �- SI' h �-- ��,�" '� �'� c�� m v�11 �� / � S >>n t" �� ks - 11. tf the injury occurred outdoors,what were the weather condi'ons at the time of the incident? � �U��. � ��n ��.�c � , Report iD Number (continued over) � � ' (Intemal Use Onty) T 12. Did the injury occur on the campground? If not,specify the off-site location where the injury occurred. (please describe the exact location) .�� s c� r � 13. What body part(s)were injured: � � OL Head/Skull 02,Face 03.Neck 04.Arm O5.Hand 06. Back 07.Abdomen 08.Leg 09.Ankle 10.Foot 11. Other,ptease specify 14. How did injury occur? � i O1.Falling OZ.Collision with person or object V' 03.Sh�uck by another person or ob'ect � � � 04.Drowning or near drowning 05.Bite or Sting 06.Cut p7,g� ! ' 08. Other,please specify - � � � 15. Where was the injured person treated? i Ol. Treated in camp infirmary 02.Treated in hospital Emergency Room,Physician's Offic�_____��/{��j" �/� ,� 'Lev 03. Admitted to Hosprtal 04.Other,please specify �' -E? i��, d�; �' .��;�ji' � 16. Was the camper sent home as a result of the injury? """"2��M��, �� l > � `'� �� Yes No� , 17. Was more than one camper injured? Yes No � If Yes,how man ? y k { I ! 18. Did the injury involve alleged abuse/neglect? Yes No "V i 19. What changes tivere made in the camp,its environment,or operation as a result of this injury to prevent a reoccurrence? PI e describe specific changes made: i � - - —_ _--- _ �� b��S h�� .�'.� .� � �� r�ke- �� b �'- �1 sd hor��2 ��r� h �� ' n�� s�;,� � J�er�' 1' : � �' ls_ PLEASEMAIL OR FAX CAMPER INJURYREPORTS TO: MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH BUREAU OF ENVIRONMENTAL HEALTH COMNIUNITY SANITATION PROGRAM 250 WASHINGTON STREET-7th FLOOR BOSTON, MA 02108-4619 TELEPHONE(617)-62�-5757 ' FAX(617)624-5777 (Revised May 2008) I � t � � � i MASSACHUSETTS DEPARTMENT OF PUBLIC HEA.I:,'�'I-� �. �`� � � COMMUNITY SANITATION PROGRAM ��"� � ' � � l7 J RECREATIONAL CAMPER INJURY REPORT TORI�'� � §�� ' � ; In accordance with M.G.L. c. 111, §§ 3 and 127A and 1fl5 CMR 430.000:Minimum Sanitation and S`�f�%yStandards for � Recreational Camps for Children(State Sanitary Code Chapter N), 105 CMR 430.154 specifically 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 horne,or is brought to the hospital or a physician's office and where a � positive diagnosis is made. Such injuries shall include,but shall not necessarily be limited to,those where suturing or � resuscitation is required,bones are broken,or the child is admitted to the hospital.A copy of each injury report must be ; sent to the Massachusetts Department of Public Health within SEVEN 7 days of the occurrence of the injury. PLEASE PROVIDE A COMPREHENSIVE AND THOROUGH RESPONSE TO EVERY QUESTION. i -� ' ��► ��err �f . 1 � r��a �� ` 1. Name of Camp: �� 2. Address: -4l�v v v' �-1° �� - City/Town ��m f +�� /` � ; [j�/ y� � � ��_ ; , 3. Name of Camp Director:. � Y V ��J/ G�'I 4.Telephone: �U � ' ✓ � �A�`�� '��s�'rc�rn=�C�= �.�3- 83�� 5. Today's Date: �' �CJ '�� 6. Date of Injury:�• 1 7• 1�- 7. Time of Injury: ��o Od (AMlPM) ! 8. Did the injury invotve a camper,staff person or both: �,4-N1 P� �. 9a. Age of Camper and/or Staff Person: � ��L✓-� 9b. Gender: Male `��5 Female ' 10. Briefly describe the incident and subsequent injury: (Please do not include aersoaal identifviag information) 5'f�11� N r �-� U� w � � �� P t��`l►,��- �A -w,�- ,3 A-�i.. ��i.�✓�— �R�� 'c � t��-- ST�r,✓r 'S N�+� �4.,✓'►� rv�cic N1T Th't ��95� 3art�2� c�F �inr ��.�r l�rrBt'�L✓'��, sT v,�.v7 �,✓rts RfZ_�IVGN; ?� 1 n/ �i Rn�R'�'�� vALV�4��. a ; tiT ll 1��.+�/�i ��i��"C1 f� �fG-�S csi- �-�'��4-� 1.✓?VfZ4� p�In/ t�✓ i✓��K 'J''R�'4�� ,/� f C c S�n�c- �4C�-r,4n�(�r�r�r��•✓ ,r ��✓.ii ��5�k✓A�Ttarv M�9 C�rN .�G ft t� . _.�4,�7'E�. �4 Pf'�-��` i-! U M��✓ f S�v Dt N"�� La G �gc RE.�tSt`t> �F-�✓l� �S 1`i�8.�/T� ��G�1K L�' � QV�R t�r �[R�� .�4�►/_D t l.v,�.� � t' i v �r=il��Y c'c��7-I�L 13 U�y� al 1! G4�C��b � C S P I•+�� N�� Po�+"�EN�.� �Nd�1�(t=�1 d F G t-��•✓G�G `t'R�/5 P�2 tt D rv t�r�. -- l 1. If the injury occurred outdoors,what were the weather conditions at the time of the incident? M o 5 L-� 5 v ►�� I�`� _ � Report ID Number �� ;� (continued over) � Q � � r• �. pntemal Use Only{ ..n„aj , 12. Did the injury occur on the campground? If not,specify the off-site location where the injury occurred.' (please describe fhe exact location) �� . �-`� �r�t � �A �� P r7 � 13. What body part(s)were injured: 01.Head/Skull i� 02.Face 03.Neck _�04.Arm 05.Hand 06. Back 07.Abdomen O8.Leg 09.Ankle 10.Foat ' 11. Other,please specify 14. How did injury occur? Ol.Falling ,/ 02. Collision with person or object � 03. Struck by another person or object 04.Drowning ar near drowning 05.Bite or Sting 06.Cut 07.Burn , - - - I18.-f3tnei;�slease specify , { � � 15. Where was the injured person treated? i � Ol. Treated in camp infirmary t/ 02.Treated ' osprta Emergency Room Physician's O�ce ✓� 03. Admitted to Hospital 04.Other,please specify V i.. C � 16. Was the camper sent home as a result of the injury? . Yes No_� 17• Was more than one camper injured? Yes No_� If Yes,how many? � i 18. Did the injury involve alleged abuse/neglect? Yes 1�Io � � s , 19. What changes were made in the camp,its environment,or operation as a result of this injury to prevent a reoccwrence? � � ___—_ F:,.�ase describe specific changes made: � � -- __ _ _�� _ i � __ _ _ j � � �� PLEASEMAIL OR FAX CAMPER INJURYREPORTS TO: � MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH $UREAU OF ENVIRONMENTAL HEALTH COMMUNITY SANTTATION PROGRAM 250 WASHINGTON STREET-7th FLOOR BOSTON, MA 02108-4619 TELEPHONE{617)-624-5757 FAX(617)624-5777 (Revised May 2008)