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Submit a Fireworks Injury Report

  1. Creating an account or logging in to Form Center is optional and is not required to submit this form.
  2. Sex of Injured Person
  3. Nature of Injury
  4. Part of Body with Largest Percentage of Injury
    Check All That Apply
  5. Type of Fireworks Causing Injury
  6. Activity or Injured Party
  7. If injured party was the operator/shooter or assistant, what was used to light the firework?
  8. Disposition of Injured Party
  9. Type of Facility
  10. If You Have No Injuries to Report, Please Check the Following Box
  11. Leave This Blank:

  12. This field is not part of the form submission.