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. 

Fireworks Injury Survey Submit Online

Sex of injured person

Nature of injury (please check one)







Part of body with largest percentage of injury (check all that apply)









Type of firework causing injury (please check one)









Activity of injured party (please check one)



If Injured Party was the Operator/Shooter or Assistant, What was Used to Light the Firework?



Disposition of injured party (please check one)






Type of Facility (please check one)



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