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6. Sex. Check the box to indicate the sex of the person injured.

7. Date of accident. Use the same format as for today's date, that is, month, day, year in numerals.

8. Time of accident. Use a 24 hour clock to record times. Thus 2:20 a.m. is recorded 0220 while 2:20 p.m. is 1420. Listed below are the equivalent times for each hour:

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9. Location of the incident. Both a general location and a specific location are to be checked. If the injury occurs on an area used regularly by the camp but not technically its property, such as a lake or a public park within easy walking distance, check “on the campgrounds”; otherwise, check “off the campgrounds." In either case, go on to check the specific location.

10. Type of incident. Check the box which best describes the type of incident. In the case of animal bite or sting, write in the kind of animal, The “other” category is included in case of an unusual incident. Do not list skin problems from poison ivy or similar plants on this form. Use the illness form. However, if leaves from such a plant are eaten, this form should be used.

11. Activity at time of the incident causing the injury. Some definitions of these activities follow:

04 “Transit in conveyance" means the use of any transportation during part of the camp program such as hayrides, travel, etc.

21 "Climbing (Technical)is rock, ice, snow, or mountain climbing where special equipment such as ropes, climbing hardware, ice axe, or other equipment should be used.

Wide games" include a variety of games usually between two teams with the objective of capturing territory, property ,or people. Examples: prisoner's base, capture the flag. Name the game involved if this box is checked.

"Competitive sportsrefers to active games which are usually confined to a well defined area such as a playing field, arena, or court. It does not include water sports which should be classified in one of the activities

10 through 18. Name the sport involved competitive sports are checked. If some activity other than one of those listed was involved, then describe the activity and check the box labelled "other."

12. The accident agent. The specific event that precipitated the accident. For example, if the camper was walking through the woods and tripped over a log, the log is the accident agent. (A later question gets at the injury agent which is the object causing the injury.)

13. Time interval between injury and treatment. Check appropriate box.

14. Injury data. The matrix gives the part of body injured and the type of injury. Check the appropriate boxes indicating these two items-for example, in the case of the boy playing baseball who broke his forearm, the box formed by the column headed “fracture" and the row "lower arm" would be checked. Check one box for each injury sustained. Use body ram when appropriate to indicate the injury and extent of injury pictorially.

15. Injury agent. Unlike the “accident agent,” the injury agent is that object that specifically caused the injury. It may or may not be the same as the accident agent. For example, if a camper walking along a trail trips over a log and cuts himself on his knife, the log is the accident agent, while the knife is the injury agent. Possibly there could be more than one injury agent. In the above example, the camper might also strike his head against a tree. The tree would be a second injury agent.

16. Extent of treatment. Check the appropriate entry, providing duration of stay in hospital or infirmary in days if applicable.

17. Disposition. Check appropriate box.

18. Extent of disability. This question assesses the type and extent to which the camper was disabled as a result of the accident. A total disability is one in which the individual is completely incapacitated such as in the case of total paralysis from the neck down.

19. Was safety equipment available for the camper's use! For example, in a game of football, were helmets provided? Were life jackets used in boating? If equipment was available, was the camper using it properly. Check appropriate boxes.

20. At the time of the accident, how many and what type of supervisors were present on the scene! For example, 3 senior life guards, 1 counselor intraining, etc.

21. Were other campers present at the accident location. If yes, indicate the approximate number.

22. Did the camper violate a camp rule! Example: swimming in a "no swimming location."

23. Was the nature and type of supervision at the time of the accident in violation of a camp rule! For example, improper number of supervisors or boat not inspected.

24. Was there more than one camper injured in this accident! Check yes or


25. Were any changes made! Specify any new rules, installation of equipment, lectures to staff or campers and so forth. Narrative Section

Items A through F are mainly for supplemental information, but when properly completed give a flavor to the injury report that may not come through the lists of information in the separate questions.

A. Unusual characteristics. The characteristic does not have to be directly relevant to the accident. For example: Indicate the injured person is overwight even though this seems unrelated to his cutting his hand on a piece of glass.

B. Previous accident history. If it is known that the camper has been injured previously this year, other years, in camp, at home, or whatever, the information should be recorded.

C. Stre88. Appropriate examples are given on the form.

D. Describe the accident. Include such things as weather, (rain, fog, clear), lighting, (dusk, night, floorlamp, etc.), temperature, etc. as well as the events immediately surrounding the accident.

E. Preventable! How? This is an important aspect of the study and involves your opinoin of whether the injury could be prevented.

F. Who provided the information! Insert name and title and relation to the incident (such as “treated person"). Sign the form in case there is a need to follow up any information presented.


When to Complete an Illne88 Report

An illness form is to be completed each time a camper reports to the person charged with camp health care for attention for a separate condition. Returning for the treatment of the same case of poison ivy would only be one form; returning on several separate days for separate headaches or other complaints would require a form each time.

1. Today's date. Use numbers for month, day, year. Example: 6/15/73 for June 15, 1973.

2. Camp name. May be abbreviated.

3. Camp JD number. Each participating camp is assigned a number to be used on all forms from that camp.

4. Camper ID number. Number your cases serially within a camp session. Start with 001 and number consecutively. (This may be done by the Field Representative when he collects the forms.)

5. Age. Report age in years; example: the ages 8 years 4 months and 8 years 10 months are both recorded as 8 years.

6. Sex. Check male (M) or female (F).

7. Briefly describe the illness. Insert a short narrative description of the complaints, symptoms, when they started and other significant information. Example: 8 year old male camper felt abdominal pain after eating super, Had diarrhea during evening. Reported to infirmary at 2200 hours with elevated temperature.

8. Initial visit. Give date the camper was seen for the illness; use number for month, day, and year. Example: 6/15/73. Record time the camper was seen using the 24 hour clock (0-2400); Example: 3:40 p.m. is recorded as 1540 hours. (See instructions for item 8 of Injury Report form in case you are unfamiliar with using the 24 hour clock times.) Check who saw and treated the camper. If none of the entries applies, enter the person's qualifications under "other, specify—.” More than one entry can be checked. Check where the camper was seen, or provide under "other site, specify."

9. Time intervul. Record the closest possible estimate of the time interval between when the camper sought medical attention and when it was provided.

10. Duration of symptoms. Check appropriate box.

11. Scen for same condition. Check whether the camper had previously been seen for complaints relating to this same illness, and if so, how long before this visit.

12. Past medical history. This question relates to other medical facts which inight bear on the camper's illness If a stress or other illness (including homesickness) existed at the time the camper demonstrated a new pattern of illness, so indicate. Example: a homesick camper refuses to sleep in the cabin and contacts poison ivy while sleeping in a field outside. If the camper had a diagnosed chronic medical condition such as diabetes, convulsive disorder, congenital heart disease, etc., it should be listed. If the camper takes any medications on a regular basis, such as for allergy, a thyroid condition weight, control, etc., they should be listed.

13. Diagnosis. A number of common infections, inflammatory, allergic and toxic diseases have been listed and space allowed for inserting others which may occur. If no definitive diagnosis was made, or if the diagnosis is not known, then record the information in section D. In such a case, record what the illness was called and what signs and symptoms were present and recorded. Example 1: A 7 year-old camper is seen with a sore throat and fever. If the medical attenant feels the child has a "strep throat," that may be listed as the diagnosis. If the diagnosis is "streptococcal pharyngitis," that may be listed. If, on the other hand, the child is thought to have "the flu,” but no more formal diagnosis is made, do not write “flu” as the only diagnostic entry. Specify the recorded signs and symptoms—sore throat and fever—in addition to the vague diagnostic impression—"flu.” Example 2: An 8 year-old girl is seen for a rash that appeared rapidly and covered her entire body. If the medical attendant thinks the rash is due to allergy, "allergic rash" can be listed as the diagnosis. If a formal diagnosis is listed, such as “urticarial hypersensitivity reaction,” that may be recorded. If the diagnosis is unclear, do not list "none made" as the diagnosis. List the findings and impressions—“body rash with severe itching, possibly due to allergy, infection, etc."

13. E Check who made the diagnosis, or enter under "other, specify." DO NOT write in the coding box which is to be used in a later analysis.

14. Severity.Extent of disease. Shade the figures (one front and one rear view) to show the extent of illness when applicable as for rashes, skin infection, poison ivy, etc. If treatment was given. Record the medication, how it was given (orally, intramuscularly, external application, etc.) and the duration of treatment in days. Example: A 4-year-old boy develops an ear infection. He is given oral penicillin for 10 days and a decongestant for 5 days.

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Sequelae or related effects. Sequelae are disease conditions which result directly from other disease conditions or illnesses. Whenever possible, they should be included on the form.

Example 1: A 6-year-old boy with impetigo spreads the infection to the surface of his eye, which then becomes scarred, impairing his vision. Impetigo is the primary diagnosis ; corneal scarring is a sequela of that primary disease.

Example 2: A 5-year-old child has vomiting and diarrhea as part of a viral syndrome. During one vomiting episode, some of the stomach contents flow back down his windpipe. Later, he develops pneumonia. The primary disease is "gastroenteritis and vomiting-probably due to a viral infection." The sequela or related complication is "aspiration pneumonia" or "pneumonia caused by vomitus flowing into the lung."

Extent of treatment. Check the appropriate entry and record the duration of stay in the hospital or infirmary in days if applicable.

Disposition. Check appropriate box. Outcome. Check appropriate box. Examples of each type of outcome follow: complete recovery: common cold, toothache; partial disability, temporary :

asthma attack with restricted activity during convalescence; partial disability, permanent: toe infection requiring amputation; total disability, temporary : heat stroke, requiring hospitalization; total disability, permanent: meningitis with prolonged coma;

fatal: death 15. Others affected. If other campers were involved by the illness tell how many.

16. Has illne88 occurred previously? If yes, estimate how many times rather than a vague rating such as “often" or "frequently."

17. Source identified. This question attempts to determine if the illness is due to a recognized health hazard or to conditions which previously caused illness. (Examples: food poisoning, infectious hepatitis from an identified carrier). If the source is known, list it.

Example: Pet turtles and egg salad are sources of salmonella food poisoning. On the other hand, poison ivy plants are the obvious source of poison ivy and need not be listed.

Note.—Recurrent diseases without an identified source (colds, pneumonia, asthma, etc.) are not covered by this question.

18. Mode of transmission. This is the way by which a disease gets from its source to the patient.

Example: The mosquito is the mode of transmission (or vector) by which malaria gets to a patient. Similarly, a food handler may be the source of a food poisoning epidemic; the food then is the mode of transmission.

19. Laboratory work. If no lab work was done, or if it is not known whether or not lab work was done, check the appropriate boxes. If work was done, describe the tests made, if possible. If it is known that work was done, but the tests performed are not known, indicate this under "if yes, describe tests not known.

20. Parents notified? Record whether or not parents or guardians were notified. Indicate Date: Month, day, year in numbers: Example: 6/15/73. Time: Use 24 hour clock and record to nearest hour. Method : Examples: telephone, telegram, letter.

21. Changes made? Example: dishwashing procedures were modified.

22. Camper violating rule? This question asks if the breaking of a camp rule was related to the onset of illness.

Example: Wild berries, specifically identified as inedible, were eaten by campers who later became ill.

23. Comments. Insert any comments which may clarify or explain the information provided.

Please sign the form in case of a need to check the information presented.


1. Injury and illness forms are to be collected periodically. The precise scheduling for pickup may depend on many things such as the size of the camp, its distance from other camps, the kind of camp it is and so forth. In no case should forms be left more than two weeks and pickups less than one week apart do not appear warranted.

2. There should be several things accomplished in a visit to pick up forms. Some will not appropriate to specific camps; others are necessary regardless of the camp.

a. Visiting the Camp Director. A courtesy visit should be made each time the field representative visits the camp. Chat with him to determine how things are proceeding, and to listen to his complaints if any. Seemingly small talk may be of significance in interpreting statistics. For example, complaints about a long string of rainy days may indicate that activities had to be restricted, and comments about an exceptionally hot period may alert us to look for heat related problems in the data.

b. Visit the person responsible for filling out the forms. Obtain the forms and check each item to see that it is filled in properly. It might be better to do this alone and make notes on inconsistencies or incomplete data. In any event, you should then ask the person who completed the form to clarify the missing or inconsistent data. When you leave, the forms should be as complete and accurate as you can make them. Another check you should make is to compare the forms against the infirmary or first aid station log if one is kept.

c. If you are permitted to do so, you should visit a bit in the various activities in the camp. This will give a flavor of camp operation that can be invaluable in understanding the data in the forms. Similarly, talking to counselors can reveal their feelings about health and safety without directly questioning them on these points.

d. This is not a spy mission, but we do want to be as accurate as possible. Therefore, if during your visit you see a camper on crutches and his foot in a cast and you have not picked up a form that would seem to describe such a condition, inquire about it. If the infirmary has a bed patient and no illness form indicates an infirmary occupant, inquire about it. It is possible the form is being held back until the outcome is determined, but then you should be aware of that on your next visit.

e. If a new session has started or is about to start, complete a camp census form with the appropriate indvidual.

3. Mail all collected forms daily to Century Research Corporation.

4. If any question arises about any aspect of the study, call Century Research Corporation to obtain instructions. Do not make any decisions regarding the collection of data without clearing them through Century Research Corporation.


On these forms you should show the number of hours spent on each date on the camp survey, including your travel time. This time should average about 3 days per week. Your time records should be mailed in after the 15th and at the end of each month. Expense reports

These forms have columns in which to record your travel expense (at 12¢/ mile), your Per Diem for the days you work ($5.00 per day when you stay at your residence each night, and $20.00 per day if for some reason you must be away from your residence overnight), postage expenses, telephone expenses, and other necessary expenses. This form should also be mailed in after the 15th and at the end of each month. Weekly log forms

These are used to report, in capsule form, your activities for each working day. Miles and time are to be recorded in the following manner: In the space marked "Start," indicate your odometer reading and the time you leave home. At the completion of the day's work, indicate the time and odometer reading in the space marked "Complete.” Calculate the miles driven and the time spent.

In the column labelled “camp," indicate the identification number of the camp visited (example: 1,2,3, etc.).Only one camp should be listed on line. In the column labelled "Forms Completed," indicate the number and type of forms which you completed or collected that day at the indicated camp. Use the code supplied at the bottom of the form to indicate the forms completed. For example, the entry ICE, 31N, 2IL would indicate that you had obtained one Camp Census Form (CE), three Camper Injury R rts (IN) and two Camper Illness Reports (IL).

In the column labelled "Comments” indicate such things as people visited, special problems, visit accompanied by sanitarian and so forth. If you need more more, continue on the back being sure to date the item and indicate the camp number to which the comment refers. Visit schedule

This is a blue form on which you indicate your name, address and phone number and your tentative schedule of visits to a camp. This form is left with the Camp Director or other contact person at the camp so they have a record of when to expect you and information to contact you if necessary.


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