Fireworks Injury Report

DIRECTIONS: Complete one report for each fireworks-related injury treated by your facility - either with the downloadable survey or online form below. Thank you in advance for your participation. 
Sex of injured person

Nature of injury (please check one)







Part of body with largest percentage of injury (please check one)







Type of firework causing injury (please check one)









Activity of injured party (please check one)



Disposition of injured party (please check one)






If you have no injuries to report, please check the box below.