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Appendix 1 Date ________________________

Department of Health FOURMULA KONTRA PAPUTOK 2008


Region ________________________
Injury Registry
Fax: 741-7048, 743- 6076, 743- 1937 Hospital ________________________
Name Residence Date Date Type of Injury Diagnosis Type of Liquor Given(3) Disposition(4)
(Family (House #, (mm/dd) (mm/dd) (If other diagnosis, to include Firecracker Intoxica-
Name, Street, Time of Time of Involve- pls. specify) nature tion(2)
First Age/Sex Bgy., Injury Consult ment (1) and site
Name, Mun/City, Place of
Middle Prov.) Injury
Initial)
DOI: DOC: [ ] Blast/Burn WITH [ ] Yes [ ] ATS [ ] Discharged
[ ] Active Amputation [ ] No [] [ ] Admitted
TOI: TOC: [ ] Blast/Burn NO Toxoid [ ] Hama
[] Amputation [ ] None [ ] Died
Passive [ ] Eye injury [] [ ] Transferred
Place of injury: [ ] Watusi ingestion Others
[ ] GSW Stray Bullet ______________________
PHONE: [ ] Tetanus
[ ] Others
_________________
DOI: DOC: [ ] Blast/Burn WITH [ ] Yes [ ] ATS [ ] Discharged
[ ] Active Amputation [ ] No [] [ ] Admitted
TOI: TOC: [ ] Blast/Burn NO Toxoid [ ] Hama
[] Amputation [ ] None [ ] Died
Passive [ ] Eye injury [] [ ] Transferred
Place of injury: [ ] Watusi ingestion Others
[ ] GSW Stray Bullet ______________________
PHONE: [ ] Tetanus
[ ] Others
_________________
DOI: DOC: [ ] Blast/Burn WITH [ ] Yes [ ] ATS [ ] Discharged
[ ] Active Amputation [ ] No [] [ ] Admitted
TOI: TOC: [ ] Blast/Burn NO Toxoid [ ] Hama
[] Amputation [ ] None [ ] Died
Passive [ ] Eye injury [] [ ] Transferred
Place of injury: [ ] Watusi ingestion Others
[ ] GSW Stray Bullet ______________________
PHONE: [ ] Tetanus
[ ] Others
_________________
DOI: DOC: [ ] Blast/Burn WITH [ ] Yes [ ] ATS [ ] Discharged
[ ] Active Amputation [ ] No [] [ ] Admitted
TOI: TOC: [ ] Blast/Burn NO Toxoid [ ] Hama
[] Amputation [ ] None [ ] Died
Passive [ ] Eye injury [] [ ] Transferred
Place of injury: [ ] Watusi ingestion Others
[ ] GSW Stray Bullet ______________________
PHONE: [ ] Tetanus
[ ] Others
_________________
DOI: DOC: [ ] Blast/Burn WITH [] [ ] ATS [ ] Discharged
[] Amputation Yes [] [ ] Admitted
TOI: TOC: Active [ ] Blast/Burn NO [] Toxoid [ ] Hama
Amputation No [] [ ] Died
[] [ ] Eye injury None [ ] Transferred
Place of Passive [ ] Watusi ingestion []
injury: [ ] GSW Stray Bullet Others ______________________
PHONE: [ ] Tetanus
[ ] Others
_________________
DOI: DOC: [ ] Blast/Burn WITH [] [ ] ATS [ ] Discharged
[] Amputation Yes [] [ ] Admitted
TOI: TOC: Active [ ] Blast/Burn NO [] Toxoid [ ] Hama
Amputation No [] [ ] Died
[] [ ] Eye injury None [ ] Transferred
Place of Passive [ ] Watusi ingestion []
injury: [ ] GSW Stray Bullet Others ______________________
PHONE: [ ] Tetanus
[ ] Others
_________________
DOI: DOC: [ ] Blast/Burn WITH [] [ ] ATS [ ] Discharged
[] Amputation Yes [] [ ] Admitted
Active [ ] Blast/Burn NO [] Toxoid [ ] Hama
Amputation No [] [ ] Died
[] [ ] Eye injury None [ ] Transferred
Passive [ ] Watusi ingestion []
[ ] GSW Stray Bullet Others ______________________
PHONE: [ ] Tetanus
[ ] Others
_________________

1.Involvement 2. Liquor 3.Given 4.Disposition


Prepared by: intoxication ATS= Anti Discharge=
Active= injured while lighting or holding Yes- under the Tetanus Serum Discharged improve/
firecracker influence of Toxoid= recovered
Signature over alcohol (+AB) Tetanus toxoid Admitted= Admitted in
Passive= injured while watching a No- not under None= ATS or the hospital
Printed Name firecracker being lighted or passing by the influence of Tetanus toxoid HAMA= Home against
alcohol nogiven medical advice
Died