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4. Date of Injury
   Date of Injury
6. Sex of Injured Person

   1. Male
   2. Female
7. Age of Injured Person
9. Nature of Injury

   1. Burns
   2. Complaint of Pain
   3. Dislocation/Fracture
   4. Inhalation Injury/Asphyxia (Smoke)
   5. Shock
   6. Trauma/Blunt Force
   7. Wound/Cut/Bleeding
   8. Other
10. If Other, Please Explain
12. Part of Body with Largest Percentage of Injury

    1. Arm
    2. Body/Trunk/Back/Neck
    3. Eyes
    4. Face
    5. Foot
    6. Hand
    7. Head (Not Facial Area)
    8. Internal (Smoke Inhalation)
    9. Leg
    10. Other

    Check All That Apply
13. If Other, Please Explain
15. Type of Fireworks Causing Injury

    1. Bottle Rocket
    2. Firecracker
    3. Homemade
    4. Mortars/Artillery
    5. Public Fireworks Display
    6. Roman Candle
    7. Smoke Bombs
    8. Sparkler
    9. Unknown
    10. Other
16. If Other, Please Explain
18. Activity or Injured Party

    1. Assisting Fireworks Operator/Shooter
    2. Bystander Watching Fireworks
    3. Fireworks Operator/Shooter
    4. Uninvolved
20. If injured party was the operator/shooter or assistant, what was used to light the firework?

    1. Cigarette Lighter
    2. Long Handled Lighter
    3. Punk
    4. Other
21. If Other, Please Explain
23. Disposition of Injured Party

    1. Admitted for Observation
    2. Admitted for Treatment
    3. Died
    4. Refused Treatment
    5. Transfer to Burn Center
    6. Treated and Released
    7. Other
24. If Other, Please Explain
26. City of Injury
27. County of Injury
29. Completed By
30. Title
32. Name of Facility
33. City of Reporting Facility
35. Type of Facility

    1. Emergency Room
    2. Physician's Office
    3. Urgent Care
    4. Other
36. If You Have No Injuries to Report, Please Check the Following Box

    1. No Injuries to Report
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39. Email address

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