Did you experience [Injury] If Yes, where on your body was it within 24-hours after the fire or located? Repeat C2 i for next injury. explosion? If yes, go to C2 ii. If no, repeat C2 i for next injury. Yes No Injury Abrasion/scrape Broken bone/fracture Bruise Cut Dislocation Sprain or strain Burn Crush injury Severe bleeding Ear drum puncture Hearing loss Ringing in ears Whiplash Concussion Bowel perforation Eye injury Any other injuries? If yes, what was it? If applicable, specify where on your body was it located? Record below. 1. 2.
Did you experience [Injury] within 24-hours after the fire or explosion? If yes, go to C2 ii. If no, repeat C2 i for next injury. If Yes, where on your body was it located? Repeat C2 i for next injury. Injury Yes No Abrasion/scrape Broken bone/fracture Bruise Cut Dislocation Sprain or strain Burn Crush injury Severe bleeding Ear drum puncture Hearing loss Ringing in ears Whiplash Concussion Bowel perforation Eye injury Any other injuries? If yes, what was it? If applicable, specify where on your body was it located? Record below. 1. 2.
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