Get Action Paputok Injury Reduction Form

Filling out the Action Paputok Injury Reduction Form online is a crucial step in documenting and addressing fireworks-related injuries. This guide will walk you through each section of the form, ensuring that you understand how to provide the necessary information accurately.

Follow the steps to complete the form with ease.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Enter the date when you are completing the form in the designated field.
3. Specify the region where the hospital is located.
4. Provide the name of the hospital, center, or clinic submitting the report.
5. Fill in the patient’s last name, first name, and middle name in the appropriate spaces.
6. Input the patient’s permanent address, including the house number, street, barangay, municipality/city, and province.
7. Enter the patient’s contact number, including landline and mobile.
8. Indicate the sex of the patient by checking the appropriate box.
9. Record the patient's age in years, months, and days.
10. Fill in the date of the injury in the mm/dd/yyyy format.
11. Document the date of consultation using the same mm/dd/yyyy format.
12. Write the time of consultation in military time format.
13. Specify the address where the injury occurred, detailing the street, barangay, municipality/city, province, and region.
14. Select whether the patient was actively or passively involved in the incident.
15. Check the nature of the injury from the provided options, specifying if it is fireworks-related.
16. Indicate if there were multiple injuries and specify the type of injuries sustained.
17. Provide the diagnosis that includes the nature and site of the injury.
18. Enter anatomical location relevant to the injury.
19. Write the name of the firecracker involved in the incident.
20. Indicate whether liquor intoxication was present.
21. Select the treatment given to the patient from the provided options.
22. Specify the disposition of the patient upon release.
23. Fill in the name and signature of the person completing the form.
24. Enter the name and signature of the officer-of-the-day.
25. Once all sections are completed, save your changes, download, print, or share the form as necessary.

Complete your documents online today for a smooth filing process.