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New Jersey Department of Health Consumer, Environmental and Occupational Health Service PO Box 369 Trenton, NJ 08625-0369 ANNUAL ACCIDENT REPORT YOUTH CAMP SAFETY ACT INSTRUCTIONS: In accordance with N.J.A.C. 8:25-5.1(f), report all accidents resulting in death or serious injury. DO NOT INCLUDE minor injuries which require only first aid treatment and which do not involve professional medical treatment, loss of consciousness, restriction of activity or motion, or premature termination of the camper's stay at the camp. Complete and forward this form within five days of the closure of the camp, or no later than September 15, whichever date is sooner. Use the codes provided to complete the requested information. If no reportable incidents occurred, submit a negative report by checking the box to indicate that you have "NO REPORTABLE INCIDENTS", and complete the signature area at the bottom. Email the form to [email protected] or mail this form to the address listed above; retain a copy for your records. Report Year (WEB) Permanent Camp ID Number Name and Mailing Address of Owner or Corporation (Include Camp Name) Description of Incident Check Reporting Criteria Code(s) Date of Incident 1 2 3 4 Full Name of Camper Location Code Activity Code Injury Code(s) Check If Death Resulted Signature of Responsible Official Date Name Address 1 Address 2 City State Zip Location of Camp Name of Responsible Official Title of Responsible Official Email Address Telephone Number Address 1 Address 2 City State Zip Camp Name ONLY SELECT THIS BOX IF YOU HAVE NO INCIDENTS TO REPORT 5 CB-15 AUGUST 20 Page 1 of 2

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Page 1: INSTRUCTIONS: In accordance with N.J.A.C. 8:25-5.1(f ... · YOUTH CAMP SAFETY ACT INSTRUCTIONS: In accordance with N.J.A.C. 8:25-5.1(f), report all accidents resulting in death or

New Jersey Department of HealthConsumer, Environmental and Occupational Health Service

PO Box 369Trenton, NJ 08625-0369

ANNUAL ACCIDENT REPORTYOUTH CAMP SAFETY ACT

INSTRUCTIONS:In accordance with N.J.A.C. 8:25-5.1(f), report all accidents resulting in death or serious injury. DO NOT INCLUDE minor injuries which require only first aid treatment and which do not involve professional medical treatment, loss of consciousness, restriction of activity or motion, or premature termination of the camper's stay at the camp. Complete and forward this form within five days of the closure of the camp, or no later than September 15, whichever date is sooner. Use the codes provided to complete the requested information. If no reportable incidents occurred, submit a negative report by checking the box to indicate that you have "NO REPORTABLE INCIDENTS", and complete the signature area at the bottom. Email the form to [email protected] or mail this form to the address listed above; retain a copy for your records.

Report Year(WEB)

Permanent Camp ID Number

Name and Mailing Address of Owner or Corporation (Include Camp Name)

Description of IncidentCheck Reporting Criteria Code(s)Date of

Incident1 2 3 4

Full Name of Camper LocationCode

ActivityCode

InjuryCode(s)

Check IfDeath

Resulted

Signature of Responsible OfficialDate

Name

Address 1

Address 2

City

State

Zip

Location of Camp

Name of Responsible Official

Title of Responsible Official

Email Address

Telephone Number

Address 1

Address 2City State Zip

Camp Name

ONLY SELECT THIS BOX IF YOU HAVE NO INCIDENTS TO REPORT

5

CB-15 AUGUST 20

Page 1 of 2

Page 2: INSTRUCTIONS: In accordance with N.J.A.C. 8:25-5.1(f ... · YOUTH CAMP SAFETY ACT INSTRUCTIONS: In accordance with N.J.A.C. 8:25-5.1(f), report all accidents resulting in death or

(Instructions and Codes)

ANNUAL ACCIDENT REPORTYOUTH CAMP SAFETY ACT

INSTRUCTIONS AND CODES

INSTRUCTIONS:

In accordance with N.J.A.C. 8:25-5.1(f), report all accidents resulting in death or serious injury. DO NOT INCLUDE minor injuries which require only first aid treatment and which do not involve professional medical treatment, loss of consciousness, restriction of activity or motion, or premature termination of the camper's stay at the camp. Complete and forward the CB-15 form within five days of the closure of the camp, or no later than September 15, whichever date is sooner.

Use the following codes to complete the requested information.

If no reportable incidents occurred, submit a negative report by writing "NO REPORTABLE INCIDENTS" across the front of the CB-15 form, and complete the signature area at the bottom. Email the form to [email protected] or mail the form to the address listed; retain a copy for your records.

REPORTING CRITERIA CODES:

1 - Medical Treatment by Off-site Professional Required (EMT, Ambulance, Urgent Care,

Hospital) 2 - Camper/Staff Loss of Consciousness3 - Involved Restriction of Activity or Motion4 - Camper/Staff Sent Home Early 5- Involved Quarantine or Isolation Restricting

Camper/Staff from Camp for Several Days orWeeks

LOCATION CODES:

1 - General Camp Grounds2 - Off Site3 - Playground4 - Pool/Lake/Other Body of Water5 - Sporting Field/Gymnasium6 - Transport To/From Camp

ACTIVITY INVOLVED CODES:

01 - Archery02 - Baseball03 - Basketball04 - Bicycling05 - Board Games06 - Boating07 - Bowling08 - Campfire Making or Tending09 - Commutation10 - Dancing/Theater11 - Dodgeball12 - Football13 - Go-Kart14 - Gymnastics/Cheerleading15 - Hiking/Walking/Running16 - Hockey (Ice or Field)17 - Horseback Riding18 - Indoor Games19 - Kickball20 - Miniature Golf21 - Playground Equipment22 - Rope Course/Rock Climbing/Bouldering23 - Skating (Roller/Ice/Skateboard)24 - Soccer25 - Swimming26 - Tennis27 - Volleyball28 - Woodworking (Whittling, Woodburning)29 - Wrestling/Martial Arts30 - Does Not Involve Activity/Not Specified

TYPE OF ILLNESS/INJURY CODES:

01- Allergic Reaction (to Bite, Sting or Medication)02 - Back Injury03 - Bite (Animal)04 - Bite (Human)05 - Bites (Insect)/Sting/Skin Rash/Poison Ivy/Ringworm06 - BreathingDifficulty/Respiratory/Asthma/Hyperventilation07 - Bruise/Contusion/Abrasion08 - Burn09 - Dental/Mouth Injury10 - Ear Injury11 - Excess of Heat or Sun (Heat Stroke, Exhaustion,Rash, Cramps and Sunburn)12 - Eye Injury/Disease (including Conjunctivitis)13 - Fainting/Seizure14 - Food Poisoning15 - Fracture16 - General Illness Not Related to COVID (Fever,Nausea, Vomiting,Stomach Pain, Menstrual Cramps,etc.)17 - Head/Neck Injury (including Concussion, Loss ofConsciousness)18 - Laceration/Puncture/Splinter19 - Nosebleed/Nose Injury20 - Sprain/Strain/Dislocation (Muscle/Ligament/Joint)21 - COVID-19 Lab Confirmed22- COVID-19 Close Contact

CB-15 AUGUST 20

Page 2 of 2

[email protected]

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