Fireworks Injury Case Report Form

Incident Date

Date

Incident Time

Hour Minutes

AM/PM Option

Incident Location / Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Incident Type / Fireworks Situation

Injured Person’s Name

First NameLast Name

Age

Injury Description

Body Part(s) Affected

Severity of Injury

Medical Attention Received

Current Condition / Status

Type of Fireworks Involved

Who Ignited or Handled the Fireworks?

Were Supervision or Safety Instructions Present?

Brief Description of What Led to the Injury

Witness Name

First NameMiddle NameLast Name

Witness Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Witness Email Address

example@example.com

Can the witness provide photos or other evidence?