Fill and Sign the Affidavit Existence Form

Organizational Camp Accident / Fatality Report State of Oregon Oregon Health Authority Public Health Division This report must be completed for every serious accident, those requiring off-site treatment, or any fatality involving an organizational camp program. It is the responsibility of the camp operator to submit the completed form promptly to the Oregon Health Authority, Organizational Camp Program, 800 NE Oregon, Suite 608, Portland, OR 97232-2162 Food, Pools and Lodging–Health & Safety 800 NE Oregon Street, Suite 608 Portland, Oregon 97232-2162 Phone (971) 673-0451 FAX (971) 673-0457 Communicable diseases are to be reported to the county health department communicable disease program. Date of Incident Time: am pm Accident ID # YYYY – MMDD - County # Official Use Only Victim Information First Name Address MI Number Last Name Street City or Town Apt.# State Zip Code SEX:  M  F Age of Victim:(yrs)  Fatal  Non-Fatal Camper  Area of the Body Injured: (Check all that Apply) Type of Injury: (Check all that Apply)  Head  Arm / Hand / Finger  Other (Specify)       Trunk  Leg / Foot / Toe Abrasion or Contusion Concussion Burn Allergy / Asthma Reaction Other (Specify)     Staff  Strain or Sprain Fracture Laceration Diabetic Emerg. Treatment Required: (Check all that Apply)  No Treatment  First Aid  Doctor’s Office/Emergency Room  Other (Specify)  CPR (  Manual  AED  Oxygen )  Admitted to Hospital Camp License # Camp Information Name of Camp Address Number Street City Contact Person State Zip Code Position Phone Was the activity causing the injury supervised ?  Yes  No The supervision was provided by Trained Camp Staff  Untrained or Volunteer  Side 1 of 2 Side 2 of 2 Location of accident:           Cause of injury or fatality: (Check all that apply)            Campsite / Cabin Dining Hall / Food Service Waterfront * Canoeing / Boating Target Sports Horseback Riding Ropes Course Arts & Crafts Hiking Trail Off-site activity:_____________________  Other:_____________________________ Horseplay Improper Use of Equipment Poor / No Supervision Equipment Failure Activity Area Design Lack of Safety Equipment Non-use or Improper Use of Safety Equipment Drug / Alcohol Use or Abuse Use of chemicals, paint, cleaning supplies Weather Other (describe) * For swimming pool /spa incidents please use the Public Swimming Pool Accident Report form. Were Others Injured:  Yes  No If Yes, Name(s) Describe what happened: (Please be legible) Print or Type Name & Position: Signature: Date: PHD 101 (rev01/31/2011)