Form Center

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.)

Leave This Blank:


78. 1. Receive an email copy of this form.
79. Email address

    This field is not part of the form submission.

80. Submit

* indicates a required field