Form Center

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 Address
17. City
18. County
19. State
20. Zip Code
22. V. Patient's Sex
    -- Select One --MaleFemale
24. VI. Patient's Date of Birth
26. VII. Patient's Race
    -- Select One --White, Non-HispanicHispanic/LatinoAsian/ Pacific IslanderBlack, Non-HispanicNative American/American IndianUnknownOther
28. VIII. Date of Burn Injury
30. IX. Time of Burn Injury (24hr)
32. X. Was Burn Sustained at Work?
    -- Select One --YesNo
34. XI. Incident Location/Address
36. City
37. County
38. State
39. Zip Code
41. XII. Location of Injury
    -- Select One --HomeFarmMine/QuarryPublic BuildingStreet/HighwayIndustrial PlaceRecreational PlaceResidential InstitutionUnknownOther
42. If other, specify
44. XIII. Cause of Burn (E-Code)
46. XIV. Describe Cause
48. XV. 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
50. XVI. Percent of Body Burned

    1. Unspecified
52. 2nd Degree
53. 3rd Degree
54. Total Surface Area Burned
56. XVII. Inhalation Injury?
    -- Select One --YesNo
58. XVIII. Ventilator Support Used?
    -- Select One --YesNo
60. XIX. Skin Grafting Done?
    -- Select One --YesNo
62. XX. Hospital Length

    1. Emergency Room Only
63. Total Days in Hospital
65. XXI. 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
67. If other, specify
69. XXII. Date of Report
71. XXIII. Name of Person Making Report
72. Title of Person Making Report
74. 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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77. Email address

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