National Burn Center Reporting System Report Form

For an incident that fits the definition of a reportable case, please complete this form. Use the TAB key or your mouse to go to each data area.

Victim Information

Name:

Date of Birth:

Sex: FemaleMale

Initial admission diagnosis:

Prognosis:

Days in this hospital:

Days in other care facility:

Current Status: In hospitalDischarged

Address:

Telephone Number:

Parent/Guardian Name:

Incident Information

Date of Incident:

Location of Incident: ResidenceOther:

Fire Occurred: IndoorOutdoor

Type of Incident:
Fire confined to heat source and victim
Fire extended beyond heat source and victim
Explosion, no fire
Other:

Incident Cause: (Heat or fire source)

Incident description: (sequence of events)

Describe clothing involved:

Was clothing used as sleepwear during incident?
YesNoDon’t know
Did clothing: IgniteSmolderMelt (check all that apply)

Reporting Burn Center: Name of Person Reporting:

OMB Control Number 3041-0029

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