Skip to Main Content
Loading
Close
Loading
About Us
Divisions
Resources
I Want To...
Home
Form Center
Form Center
Search Forms:
Search Forms
Select a Category
All Categories
Above Ground Storage Tanks
Boilers
Certificate Requests
Contact
Elevators
Emergency Response
Extinguishers, Alarms, & Sprinklers
Facilities
Fire Prevention Education
Fireworks
Get Alarmed KS
Healthcare
Industrial Hemp Processing
Insurance
Investigations
Kansas Open Records Act Request Forms
Lending Library
National Fire Incident Reporting System Training
Propane
Tom McGaughey Fire Service Award
By
signing in or creating an account
, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.
Kansas Burn Injury Reporting System
Sign in to Save Progress
This form has been modified since it was saved. Please review all fields before submitting.
This form must be completed for 2nd and 3rd degree burns involving 20% or more of the patient's body.
I. Name of Facility
II. Facility Address
City
County
State
Zip Code
III. Patient's Name (First, M, Last)
IV. Patient's Address
City
County
State
Zip Code
V. Patient's Sex
-- Select One --
Male
Female
VI. Patient's Date of Birth
VII. Patient's Race
-- Select One --
White, Non-Hispanic
Hispanic/Latino
Asian/ Pacific Islander
Black, Non-Hispanic
Native American/American Indian
Unknown
Other
VIII. Date of Burn Injury
IX. Time of Burn Injury (24hr)
X. Was Burn Sustained at Work?
-- Select One --
Yes
No
XI. Incident Location/Address
City
County
State
Zip Code
XII. Location of Injury
-- Select One --
Home
Farm
Mine/Quarry
Public Building
Street/Highway
Industrial Place
Recreational Place
Residential Institution
Unknown
Other
If other, specify
XIII. Cause of Burn (E-Code)
XIV. Describe Cause
XV. Body Areas Burned
Face, Head, Neck
Wrist, Hand
Trunk
Upper Limb(s)
Lower Limb(s)
Internal Organs
Specified
XVI. Percent of Body Burned
Unspecified
2nd Degree
3rd Degree
Total Surface Area Burned
XVII. Inhalation Injury?
-- Select One --
Yes
No
XVIII. Ventilator Support Used?
-- Select One --
Yes
No
XIX. Skin Grafting Done?
-- Select One --
Yes
No
XX. Hospital Length
Emergency Room Only
Total Days in Hospital
XXI. Disposition
Left AMA
Transfer, to acute care facility
Transfer, to burn center
Transfer, burn center to burn center
Unknown
D/C, extended care facility
D/C, home, w/follow-up care
D/C, home, no follow-up care
Died
Other
If other, specify
XXII. Date of Report
XXIII. Name of Person Making Report
Title of Person Making Report
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.)
Leave This Blank:
Receive an email copy of this form.
Email address
This field is not part of the form submission.
Submit
* indicates a required field
Accessibility Policy
Contact Webmaster
Terms of Use
Press Releases
Arrow Left
Arrow Right
[]
Slideshow Left Arrow
Slideshow Right Arrow