subject_line
New Jersey Department of Community Affairs
Division of Fire Safety - Civilian Burn Patient Form
Date of Burn:
*
+
Alarm Time:
*
Age of Victim:
*
Date of Birth:
*
Gender:
*
Female
Male
Victim's Name:
*
Part(s) of Body Burned:
*
% BSA:
TYPE OF BURN: (Check One)
*
Chemical
Explosion
Fire
Flame
Sparkler/Novelty Device Burns
Illegal Fireworks Burns
Scald Burns
Electrical Burns
Smoke Inhalation
Other:
Other:
SEVERITY: (Check one)
*
Minor
Moderate
Severe
Victim's Address:
(Address where burn reportedly occurred)
*
Zip:
*
City:
*
County:
*
Victim's Home Address:
*
City:
*
Zip:
*
Fire Department Name:
*
FDID:
*
Reporting Agency:
*
Name of Reporting Person:
*
Phone Number Reporting Agency:
*
Cause of Fire:
*
Type of Occupancy:
*
Room of Origin:
*
Detector Present:
*
Yes
No
Unknown
Detector Operated:
*
Yes
No
Unknown
Remarks:
Hospital Victim was Transported to:
Please enter e-mail address below; a copy of this form will be sent after you have submitted the report.
*