Louisiana Department of Public Safety and Corrections
Public Safety Services
Office of State Fire Marshal

 

BURN INJURY REPORT

Title 14:403.4 (Criminal Code)

Please follow the instructions very carefully, reading all the questions thoroughly before submitting the form. If any information is unknown, leave blank and go on to the next block.

Date Reported
Patient Information


Incident Information




































Reporting Facility Information

 

Louisiana Office of State Fire Marshal

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Louisiana Office of State Fire Marshals
Louisiana Office of State Fire Marshals