Iowa Department of Public Safety - State Fire Marshal Division Burn Injury Report Submission of this report is required pursuant to Iowa Statue Section 147.113A. https://www.legis.iowa.gov/docs/code/147.113a.pdf Patient Full Name: Street Address: County: Street address where burn occured: State: Zip Code: Patient Gender: ☐ Male ☐ Female Area(s) of body injured: %1 st %2 nd %3 rd %Total Initial Burn Estimate: 12+ Hr. Burn Estimate: 24+ Hr. Burn Estimate: ☐ Check if patient sustained airway burns ☐ Check if burns compromised vision ☐ Check if burns were limited to fingers or toes Toxicology at initial hospital admission: ☐ Drug(s): ☐ Admitted Use ☐ Tested – Value: Alcohol (Y/N): ☐ Admitted Use ☐ Tested – BAC: ☐ Face, ☐Head ☐ Neck ☐Shoulder ☐ Chest ☐Abdomen ☐ Back ☐ Buttocks ☐ Groin ☐ Genitals ☐ Hand ☐ Left ☐ Right ☐ Arm ☐ Left ☐ Right ☐ Foot ☐ Left ☐ Right ☐ Leg ☐ Left ☐ Right ☐ Internal (including trachea and larynx) Causes of Burn Injury: (check all that apply) ☐ Hot Liquid Contact (scald) ☐ Chemical ☐ Hot Object Contact Describe: ☐ Contact with Burning Solid ☐ Electrical ☐ Contact with Burning Liquid Describe: ☐ Contact with Burning Vapor ☐ Explosion ☐ Direct Flame Contact Describe: ☐ Fireworks Type: ☐ Flammable Liquid ☐ Outside Fire (grass, camping) ☐ Radiation ☐ Sunburn ☐ Structure Fire ☐ Smoking ☐ Other: ☐ Unknown: Reporting Facility – Name/Address/City/Zip: Attending Physician: Reporting Person: Date Reported: Mail completed form to your local law enforcement agency per 147.113A. Please mail a copy to: Iowa State Fire Marshal Division, Burn Injury Reporting, 215 East 7th St, Des Moines, IA 50319 or email a copy to Iowa State Fire Marshal Division at: [email protected] Patient Phone: City where burn occured: Date/Time of Injury: City: Patient Date of Birth:

Iowa Department of Public Safety - State Fire …%Total Initial Burn Estimate: 12+ Hr. Burn Estimate: 24+ Hr. Burn Estimate: Check if patient sustained airway burns Check if burns

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Page 1: Iowa Department of Public Safety - State Fire …%Total Initial Burn Estimate: 12+ Hr. Burn Estimate: 24+ Hr. Burn Estimate: Check if patient sustained airway burns Check if burns

Iowa Department of Public Safety - State Fire Marshal Division Burn Injury Report

Submission of this report is required pursuant to Iowa Statue Section 147.113A.

https://www.legis.iowa.gov/docs/code/147.113a.pdf

Patient Full Name:

Street Address:

County:

Street address where burn occured:

State: Zip Code:

Patient Gender: ☐ Male ☐ Female

Area(s) of body injured: %1st %2nd %3rd %Total Initial Burn Estimate: 12+ Hr. Burn Estimate: 24+ Hr. Burn Estimate: ☐ Check if patient sustained airway burns☐ Check if burns compromised vision☐ Check if burns were limited to fingers or toes

Toxicology at initial hospital admission: ☐ Drug(s):

☐ Admitted Use ☐ Tested – Value:Alcohol (Y/N):

☐ Admitted Use ☐ Tested – BAC:

☐ Face, ☐Head ☐ Neck ☐Shoulder ☐ Chest ☐Abdomen ☐ Back ☐ Buttocks ☐ Groin ☐ Genitals☐ Hand ☐ Left ☐ Right☐ Arm ☐ Left ☐ Right☐ Foot ☐ Left ☐ Right☐ Leg ☐ Left ☐ Right

☐ Internal (including trachea and larynx)

Causes of Burn Injury: (check all that apply) ☐ Hot Liquid Contact (scald) ☐ Chemical☐ Hot Object Contact Describe: ☐ Contact with Burning Solid ☐ Electrical☐ Contact with Burning Liquid Describe: ☐ Contact with Burning Vapor ☐ Explosion☐ Direct Flame Contact Describe:

☐ FireworksType:

☐ Flammable Liquid☐ Outside Fire (grass, camping)☐ Radiation☐ Sunburn☐ Structure Fire☐ Smoking

☐ Other:

☐ Unknown:

Reporting Facility – Name/Address/City/Zip:

Attending Physician: Reporting Person: Date Reported:

Mail completed form to your local law enforcement agency per 147.113A.

Please mail a copy to: Iowa State Fire Marshal Division, Burn Injury Reporting, 215 East 7th St, Des Moines, IA 50319

or email a copy to Iowa State Fire Marshal Division at: [email protected]

Patient Phone:

City where burn occured:

Date/Time of Injury:

City:

Patient Date of Birth:

mailto:[email protected]

Page 2: Iowa Department of Public Safety - State Fire …%Total Initial Burn Estimate: 12+ Hr. Burn Estimate: 24+ Hr. Burn Estimate: Check if patient sustained airway burns Check if burns

1 GENERAL PROVISIONS, HEALTH-RELATED PROFESSIONS, §147.113A

147.113A Report of burn injuries.Any person licensed under the provisions of this subtitle who administers any treatment

to a person suffering a burn which appears to be of a suspicious nature on the body, a burnto the upper respiratory tract, a laryngeal edema due to the inhalation of super-heated air,or a burn injury that is likely to result in death, which appears to have been received inconnection with the commission of a criminal offense, or to whom an application is made fortreatment of any nature because of any such burn or burn injury shall at once but not laterthan twelve hours after treatment was administered or application was made report the factto law enforcement. The report shall be made to the law enforcement agency within whosejurisdiction the treatment was administered or application was made, or if ascertainable, tothe law enforcement agency in whose jurisdiction the burn or burn injury occurred, statingthe name of such person, the person’s residence if ascertainable, and giving a brief descriptionof the burn or burn injury. Any provision of law or rule of evidence relative to confidentialcommunications is suspended insofar as the provisions of this section are concerned.2003 Acts, ch 134, §1

Sun Nov 24 20:54:51 2019 Iowa Code 2020, Section 147.113A (15, 0)

https://www.legis.iowa.gov/docs/code/147.113A.pdf

https://www.legis.iowa.gov/docs/acts/2003/CH0134.pdf