urn Injury Reporting 

Standard 
All burn injuries occurring on the facility’s premises must be reported, documented, and investigated to ensure the safety and well-being of residents, and compliance with CMS Requirements of Participation and the State Operations Manual (SOM) guidelines for long-term care facilities (LTC), as well as Connecticut Department of Public Safety regulations. 

Policy 
To ensure prompt and thorough reporting, documentation, and investigation of all burn injuries, identifying contributing factors, and implementing measures to prevent recurrence, maintaining a safe environment for residents. 

Practice Guidelines 

Burn Injury Report Form 

Facility Information: 

• Facility Name: _____________________________________________________ 

• Facility Address: ___________________________________________________ 

• Telephone: __________________ 

• Bed Capacity: ______ CCNH: ______ RHNS: ______ CCNH/RHNS: ______ 

• Date of Report: __________________ 

• Report Number: __________________ 

• Classification: A ☐ B ☐ C ☐ D ☐ E ☐ 

Follow-up Information: 

• Is this a “Follow up” to a previously submitted form? ☐ Yes ☐ No 

• (If Yes - Attach Original Report) 

Victim Information: 

4. Victim’s Name (Last, First, M.I.): ____________________________________ 

5. Sex: 

• ☐ Male 

• ☐ Female 

6. Date of Birth: __________________ 

7. Victim’s Address (Number, Street): __________________ 

• Apt. #: ______ 

• City, Town, Post Office: __________________ 

• State: ______ 

• ZIP Code: ______ 

8. Victim’s Telephone Number: (_____) ______ - ______ 

Incident Information: 

9. Address Where Burn Occurred (Number, Street): __________________ 

• City, Town, Post Office: __________________ 

• County: __________________ 

• State: ______ 

• ZIP Code: ______ 

10. Date of Injury: __________________ 

11. Time of Injury: 

• ☐ AM 

• ☐ PM 

12. Percent Burned: ______% 

13. Degree(s) of Burn(s): 

• ☐ 1st 

• ☐ 2nd 

• ☐ 3rd 

• ☐ Inhalation Burn 

14. Area(s) of Body Injured: ___________________________________________ 

15. Injury Severity (Check appropriate box): 

• ☐ 1. Moderate (treated and released) 

• ☐ 2. Serious (hospitalized) 

• ☐ 3. Life Threatening (death is imminent and/or probable) 

• ☐ 4. Dead on Arrival 

Apparent Cause of Burn Injury (Check appropriate box): 

• ☐ 1. Chemical—Contact or exposure to reactive, caustic, corrosive, or irritating substance 

• ☐ 2. Contact with Hot Object—Woodstove, stovepipe, furnace, iron, steampipe, exhaust pipe, etc. 

• ☐ 3. Cooking—Stove, oven, hotplate, barbecue, hot grease 

• ☐ 4. Electrical—Electrocution, electrical equipment, and flash burns 

• ☐ 5. Explosive—Gun powder, TNT, dynamite 

• ☐ 6. Fireworks—Sparklers, firecrackers, rockets, smoke bombs, etc. 

• ☐ 7. Flammable Liquids—Ignition of flammable/combustible liquids such as gasoline, kerosene, diesel fuel, jet fuel, lighter fluid, etc. 

• ☐ 8. Gas/Vapor Explosion—Ignition of flammable gases or the explosion of flammable liquid vapors 

• ☐ 9. Hot Liquid—Hot water, coffee, tea, hot food, hot tar, melted plastic, etc. 

• ☐ 10. Other Open Flame—Welding, matches, lighter, torch, etc. 

• ☐ 11. Outside Fires—Grass and brush, forest, bonfires, dump, trash and refuse fires, etc. 

• ☐ 12. Radiation—Burns caused by contact or exposure to any radioactive materials 

• ☐ 13. Steam—Caused by escaping steam from radiators, boilers, pipes, etc. 

• ☐ 14. Structure Fire—Any uncontained burning within a structure, including smoking accidents, trash fires, etc. 

• ☐ 15. Sunburn—Exposure to ultraviolet light, including sun lamps 

• ☐ 16. Vehicle Fire—Car, truck, plane, boat, tractor, lawnmower, etc., carburetor and engine fires, etc. 

Reporting Facility Information: 

16. Reporting Facility Name: __________________________________________ 

17. Address of Reporting Facility (Number, Street): __________________ 

• City, Town, Post Office: __________________ 

• State: ______ 

• ZIP Code: ______ 

18. Name of Attending Physician (Last, First, M.I.): __________________ 

19. Date of Report: __________________ 

Signatures: 

20. Person Filling Out Report (Signature): _______________________________ 

• CHECK HERE IF THIS INJURY HAS RECEIVED PRIOR TREATMENT (transfer patient) ☐ 

• Print Name and Title: ___________________________________________ 

• Date: __________________ 

21. Signature of Administrator: ______________________________________ 

• Date: __________________ 

To Report Burn Injuries: 

22. Immediately call the Local Fire Marshal in whose jurisdiction the injury occurred. 

23. Tell the Fire Marshal you are reporting a burn injury and give the following information: 

• Victim's name, address, and date of birth 

• Injury severity 

• Address where burn injury occurred 

• Apparent cause of burn injury 

• Date and time of injury 

• Degree of burns and percent of body burned 

• Area(s) of body injured 

• Name and address of reporting facility 

• Attending physician 

24. Complete the Burn Injury Reporting Form within 48 hours and email to norma.ruiz@po.state.ct.us or print and mail to: 

Burn Injury Reporting System 
Office of Education and Data Management 
1111 Country Club Road 
Middletown, CT 06457-9294 

Documentation and Investigation Action: 

• The charge nurse and/or department director/supervisor must document the incident and conduct an immediate investigation. 

• Use the specified Burn Injury Report Form for documentation. 

• Witnesses, if any, must be documented on the report along with their contact information. 

• The Administrator and Director of Nursing Services (DNS) must be informed of all burn injuries and review completed reports. 

• If the burn injury is of a serious nature, it shall be reported by telephone regardless of the time or day. Follow the policy/procedure for Reporting to Government Agencies and Investigation of Abuse Practice Guidelines. 

• The Administrator must notify the Director of Clinical Services and Director of Operations immediately, regardless of the time of day, if the burn injury is of a serious nature. 

• The Administrator will ensure that staff directly involved will be suspended pending a complete investigation, depending on the circumstances of the incident. 

• The Administrator is responsible for coordinating the investigation and assuring appropriate action is taken, including conducting interviews and collecting written statements from all staff involved. 

• Completed Burn Injury Report Forms must be submitted within 24 hours to the Administrator and DNS. 

• Documentation in the Nurse's Notes is done timely. 

• The resident is monitored for 72 hours post-incident with Nurse's Notes every shift, including vital signs and documentation of any ill effects. 

References: 

• Centers for Medicare & Medicaid Services (CMS), State Operations Manual (SOM) 

• Requirements of Participation for Nursing Homes, CMS 

• Connecticut Department of Public Safety Regulations 

• Guidelines for Reporting and Investigating Burn Injuries, CMS