Recreational Camp Injury/Incident Report & Notification Form

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Community Sanitation Program

Recreational Camp Injury/Incident Report & Notification Form

This form is issued pursuant to 105 CMR 430.000: Minimum Standards for Recreational Camps for Children (State Sanitary Code Chapter IV) which requires a camp to submit a report on a form available from the Department for each fatality or serious injury or incident that results in a camper, staff person, or volunteer being sent home or brought to the hospital or treated by a health care provider, and where a positive diagnosis is made (105 CMR 430.154).

A copy of this report must be sent to the Massachusetts Department of Public Health and the local Board of Health within SEVEN (7) days of the occurrence of the injury.

This form may also be used for notification of filing a 51A Report with the Department of Children and Families (DCF) (105 CMR 430.093). If using for that purpose, please ONLY fill out questions # 1 - 6.

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Date of Submission

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M-D-Y

1. Name of Camp (as stated on the Recreational Camp License)

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2. Street Address (please indicate the camp's in-session, physical address):

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City/Town:

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State:

ZIP Code:

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3. Telephone Number (in-season number):

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4. Name of Camp Director:

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5. Name of Person Completing Form:

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6. Did a suspected incident of child abuse or neglect occur at camp, resulting in the filing of 51A report to DCF? If yes, enter the date the report was sent to DCF.

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Yes

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PLEASE PROVIDE A COMPREHENSIVE AND THOROUGH RESPONSE TO EACH QUESTION.

7. Date of Incident or Injury:

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M-D-Y

8. What was the incident outcome? Please check all that apply.

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Injury

Illness

Death

Other

If other, please explain:

9. Please specify where the incident occurred:

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On camp property

Off camp property

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10. If applicable, please specify if the incident occurred at or involved:

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Waterfront/Natural Body of Water

Swimming/Wading Pool or Splash Pad

Challenge/Ropes Course

Archery/Firearms Range

Motorized vehicle

N/A

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11. Provide the total number of individuals injured from this incident.

Please submit additional forms for each injured/ill individual.

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12. Please select the age of injured/ill person (being reported on this form):

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under 7

7 to 10

11 to 14

15 to 18

19 to 22

23 or above

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13. Specify what body part was injured. Please select all that apply.

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Head, Neck and/or Face

Torso

Upper Extremity

Lower Extremity

Internal

Other

Please provided additional information on where the injury occurred. Select all that apply.

Eye

Ear

Nose

Mouth

Head

Neck

Face

Injury location not listed

Please provided additional information on where the injury occurred. Select all that apply.

Shoulder

Abdomen

Chest

Back

Hip

Injury location not listed

Please provided additional information on where the injury occurred. Select all that apply.

Arm

Elbow

Wrist

Hand

Finger(s)

Injury location not listed

Please provided additional information on where the injury occurred. Select all that apply.

Leg

Knee

Ankle

Foot

Toe(s)

Injury location not listed

Internal, please provide details here:

14. Specify the type of injury or illness. Please check all that apply:

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Allergic reaction

Bite or sting

Bruise or contusion

Burn

Cold Related Illness (ex. Hypothermia)

Concussion

Cut or laceration

Drowning

Dislocation

Fracture

Heat Related Illness (ex. Heat Exhaustion)

Incident resulting in the administration of glucagon

Loss of consciousness

Medication administration error

Muscle strain

Near drowning

Previous medical condition

Psychological or mental health condition

Seizure

Sprain

Undetermined

Viral or bacterial infection

Other

Please specify the cause of the allergic reaction:

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Food

Insect Bite/Sting

Medication

Unknown

Other

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Please specify the cause of the burn:

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Heat

Chemical

Other

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Please specify if the concussion was:

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Confirmed

Suspected

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Please specify if any of the following were required:

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Stitches/sutures

Staples

None of the above

Please specify the type of heat related illness:

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Heat Cramps

Heat Exhaustion

Heat Stroke

Other

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Please provide details on the medication administration error:

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Incorrect medication administered

Medication not administered in accordance with prescription

Other

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15. Explain in detail how the incident occurred (e.g. the type of activity was the individual was engaged in, the initial symptoms exhibited) and describe the nature of the injury or illness.

IMPORTANT: Do not include names or other personal identifying information regarding the injured individual or other involved parties.

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16. Explain how the individual was treated:

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Onsite and individual remained at camp

Onsite and individual sent home to recover

Off-site (e.g. care provided at Emergency Room, Physician's Office, Dentist's Office)

Off-site and admitted to Hospital

Other

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17. Were corrective actions taken to prevent a similar occurrence?

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Yes

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If no changes were made, please briefly explain why.

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Please check all that apply:

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Activity removed or prohibited

Changes to equipment implemented

New safety procedures implemented

Safety education provided

Training provided to staff/volunteers

Venue changed or altered

Other

Briefly explain changes implemented as a result of this incident.

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18. Has this incident been reported to the local board of health/health department?

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Yes

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