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Kansas Burn Injury Reporting System

2. This form must be completed for 2nd and 3rd degree burns involving 20% or more of the patient's body.
4. I. Name of Facility
6. II. Facility Address
8. City
9. County
10. State
11. Zip Code
13. III. Patient's Name (First, M, Last)
15. IV. Patient's Social Security #
17. V. Patient's Address
19. City
20. County
21. State
22. Zip Code
24. VI. Patient's Sex
    -- Select One --MaleFemale
26. VII. Patient's Date of Birth
28. VIII. Patient's Race
    -- Select One --White, Non-HispanicHispanic/LatinoAsian/ Pacific IslanderBlack, Non-HispanicNative American/American IndianUnknownOther
30. IX. Date of Burn Injury
32. X. Time of Burn Injury (24hr)
34. XI. Was Burn Sustained at Work?
    -- Select One --YesNo
36. XII. Incident Location/Address
38. City
39. County
40. State
41. Zip Code
43. XIII. Location of Injury
    -- Select One --HomeFarmMine/QuarryPublic BuildingStreet/HighwayIndustrial PlaceRecreational PlaceResidential InstitutionUnknownOther
44. If other, specify
46. XIV. Cause of Burn (E-Code)
48. XV. Describe Cause
50. XVI. Body Areas Burned

    1. Face, Head, Neck
    2. Wrist, Hand
    3. Trunk
    4. Upper Limb(s)

    1. Lower Limb(s)
    2. Internal Organs
    3. Specified
52. XVII. Percent of Body Burned

    1. Unspecified
54. 2nd Degree
55. 3rd Degree
56. Total Surface Area Burned
58. XVIII. Inhalation Injury?
    -- Select One --YesNo
60. XIX. Ventilator Support Used?
    -- Select One --YesNo
62. XX. Skin Grafting Done?
    -- Select One --YesNo
64. XXI. Hospital Length

    1. Emergency Room Only
65. Total Days in Hospital
67. XXII. Disposition

    1. Left AMA
    2. Transfer, to acute care facility
    3. Transfer, to burn center
    4. Transfer, burn center to burn center
    5. Unknown

    1. D/C, extended care facility
    2. D/C, home, w/follow-up care
    3. D/C, home, no follow-up care
    4. Died
    5. Other
69. If other, specify
71. XXIII. Date of Report
73. XXIV. Name of Person Making Report
74. Title of Person Making Report
76. KAR 22-5-6 Reporting of burn wounds. Hospitals which treat burn patients and doctors or other health care providers who treat burn patients at any location other than a hospital shall report all second and third-degree burn wounds involving 20% or more of the victim's body and requiring hospitalization of the victim to the state fire marshal on forms provided by the state fire marshal. Each report shall be filed no later than the Monday following the date of the first treatment of any wound. (Authorized by and implementing L. 1988, Ch. 127, Sec. 1(7); effective May 1, 1986; amended Aug. 28, 1989.)
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78. 1. Receive an email copy of this form.
79. Email address

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80. Submit

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