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19 O

DINING FACILITY

47 0

97. Equipment Improperly

Constructed or Installed

121.

Utensils Improperly Stored

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48

122. Inadequate Insect and Rodent

Control

20 O

98. Utensils Improperly Stored

Oo

21 O

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Dishwashing Facilities Inadequate

50 0

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125.

23 O

Walls/Ceilings Not Easily Cleanable

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100. Tableware Not Sanitized

101. Single Service Articles

Improperly stored

102.

Hot and Cold Running Water
Not Available

103.

Waterheater Without
Press/Temp. Relief Valve

104.

Cross Connections

105.

Accumulation of Grease on
Food Equip., Stoves, Etc.

106.

Toilet and Lavatory with
Hot/Cold Water Not Available

107. Garbage Not Stored in

Adequate Number of Approved
Containers

108. Garbage Not Removed From

Kitchen Daily

31 O

109.

Inadequate Insect and Rodent
Control

HSM-750-2 (Page 4)
6-73

INSPECTOR'S SIGNATURE

SSURANCE OF CONFIDENTIALITY - All information provided will be accorded confidential treatment and will be used for statistical purposes only:

the statistics will be presented in such a manner that no individual person or facility can be identified.

DEPARTMENT OF
HEALTH, EDUCATION, AND WELFARE
CENTER FOR DISEASE CONTROL - ATLANTA, GA 30333

CAMPER INJURY REPORT

PUBLIC HEALTH SERVICE

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22-23

01 Motor Vehicle Collision
02 Struck by Motor Vehicle
03 O Fall From Elevation
04 O Fall From Same Level
os Near Drowning
06 O Drowning
07 O Bicycle Fall or Collision
08 O Boat/Canoe - Overturn
09 O Animal Bite or Sting

SPECIFIC

24-25

01 O Fighting 02 0 Horseplay 03 O Walking/Running 04 0 Transit in Conveyance 05 O Cooking 06 O Arts and Crafts 07 Archery 08 O Riflery 09 0 Horseback Riding 10 Swimming & Snorkeling 1 Scuba Diving 12 Waterskiing 13 O Boating, Flat Bottom 14 O Boating (White Water) 15 O Boating (Overnight) 16 O Canoeing 17 Sailing 18 O Power Boating 19 Hiking (Day) 20 O Hiking (Overnight) 21 O Climbing (Technical)

O Wide Games (specify)

20-21

01 Sleeping or Living Quarters
02 O Kitchen
03 O Shower/Toilet
04 O Dining Area
05 Other Building
06 Swimming Area
07 O Boating Area (Lake, Pond)
08 White Water
09 O Other Water Area
10 O Shooting Range (Archery,

Rife, Pistol)
1 O Outpost Camp
12 0 Trail
13 O Cave, Mine, or Pit
14 O Forest
16 Sport Area or Field
16 O Arts or Crafts Area
17 Public Road/Highway
18 O Public Building or Facility
19 O Private Road
20 O Bridge

0 Other (Specify)

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Competitive Sports (Specify)

O Other (Specify)

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OOO

15.

INJURY AGENT(S) (Objects causing the injury)

61

64

16.

EXTENT OF TREATMENT

DISPOSITION

67

-1 No Treatment Required

70

1 O Return To Full Activity

-2 Treated in Camp Infirmary or First Aid Station

-2 O Return To Restricted Activity

(Length of stay):

-3 O Sent Home

3 O Treated In Hospital Emergency Room or Physicians Office

Returned Home Because Session Ended

-4 0 Admitted To Hospital

(Length of stay):

68 L

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OTHER

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17.

1

*SM-750-5 i--73

(Page 2)

(Continued on Page 3)

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D. BRIEFLY DESCRIBE HOW THE ACCIDENT HAPPENED, INCLUDING ENVIRONMENTAL

FACTORS.

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G. COMMENTS

79 5 80 2

SM-750-5 73

(Page 3)

COMPLETED BY

(Signature)

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