Form Doh 61 PDF Details

The New York State Department of Health has taken significant steps to ensure the safety and well-being of children attending various camps through the implementation of the DOH-61 form, also known as the Children’s Camp Program Report Form. This crucial document serves as a comprehensive method for reporting and addressing allegations of abuse within children's camp settings. The form meticulously gathers detailed information about the facility, including specifics about whether it operates during the day or overnight and if it caters to developmentally disabled campers. It further delves into the particulars of the event, requiring information on when and where the abuse occurred, and demands a narrative of the incident to better understand the circumstances surrounding the allegation. Victim details are treated with utmost confidentiality, ensuring the sensitive handling of their identities and the specifics of their experiences. Additionally, the form prompts for an evaluation of the supervision provided during the incident, scrutinizing whether the activity was adequately addressed in the camp's written plan, and assessing the qualifications and actions of the staff present. Alleged perpetrator information is captured with care to facilitate a thorough investigation. The completion of this form triggers a process that may involve an on-site investigation by the Local Health Department, ensuring that each allegation is followed up with appropriate action. The narrative section demands a succinct yet detailed description of the incident, conclusions drawn, and recommendations for the camp to implement, aiming to prevent such incidents in the future and ensure compliance with Subpart 7-2 regulations. This structured approach underscores the Department's commitment to the safety of children in these environments, pushing for accountability and continuous improvement in camp safety standards.

QuestionAnswer
Form NameForm Doh 61
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescamp alleg of abuse rptform environmental health manual procedure csfp 146 form

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NEW YORK STATE DEPARTMENT OF HEALTH

Allegation of Abuse

Bureau of Community Environmental Health and Food Protection

Children’s Camp Program

Report Form

 

INSTRUCTIONS: See Environmental Health Manual Procedure CSFP-146 before completing this form.

 

A. FACILITY INFORMATION

 

Facility Name:_____________________________________________________________________________________ Facility Code:____ _____ _____ ____ _____ _____ ____

 

Facility Type:

Day

Overnight

Municipal Day Camp

Are 20% or more of the campers developmentally disabled?

 

Yes

No

Date Reported ____/___/____

 

 

 

 

 

 

 

 

 

 

B. EVENT INFORMATION

 

 

 

 

eHIPS Incident Number:-_____________________ (Note: eHIPS will assign when entered into system)

 

Note: If reportable injuries occurred as a result of this incident, complete an injury report form as well

 

 

 

 

 

 

 

 

 

Date of Incident ____/___/___

Time of Occurrence ____ :____ (Military time)

Location where abuse occurred: ______

 

a. In-Camp b. Out-of-Camp

 

Where did injury occur? _____

 

 

Specify for locations marked with an asterisk: _________________________________________________________

 

a. Amusement park

e. Arts & crafts

i.

Classroom

m. Horseback area/trail

q.

Outdoor sports area

u.

Recreational hall

y. Tenting/campsite area

 

b. Aquatic area*

f.

Assembly area

j.

Cookout area

n.

Indoor sports area

r.

Parking lot

v.

Riflery area

z. Other*

 

c. Aquatic theme park

g. Bathroom/shower k.

Dining area

o.

Kitchen area

s.

Playground

w.

Ropes/challenge course

 

d. Archery area

h. Camp/trail/road

l.

Drama/stage area p.

Open field/lawn*

t.

Public highway/road

x.

Sleeping area

 

 

 

 

Nature of Allegation:

___Physical Abuse

___ Sexual Abuse

___ Both Physical and Sexual Abuse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Note: For multiple victim abuse incidents, attach additional sheets containing victim information.

C.1. VICTIM INFORMATION - Material in shaded area is confidential eHIPS Victim ID Number:_______________ (Note: eHIPS will assign when entered into system)

Name of Victim (Last, First, MI):________________________________________________________________________________________________________________________

Home Address:_____________________________________________________________________________________________________________________________________

Name of Parent or Guardian (Last, First, MI):________________________________________________________________ Home Phone Number: (______) _______-___________

Note: All the above information must be collected and maintained by LHD for appropriate investigation and follow-up.

Age: _____ Sex:

Female

Male

 

 

 

 

 

 

 

 

Status:

Camper

Developmentally Disabled Camper

CIT/Jr. Counselor

Counselor

Other Staff*

Other* Specify _______________________________________

What was the victim doing? ________

 

 

 

 

 

 

 

 

a. Amusement park rides

 

h. Classroom instruction

o. Free period

v.

Nature study/walk

dd. Swimming

b. Aquatic theme park rides

i.

Cooking

p. Games-organized*

w.

Playground equipment activity

ee. Transportation

c. Archery

 

 

j.

Court/field sports*

q. Gymnastics

x.

Playing

ff.

Travel between activities

d. Arts & crafts

 

k.

Dancing/Acting

r. High adventure activity

y.

Riflery

gg.

Walking/Running

e. Bicycling

 

 

l.

Diving

s. Hiking

 

aa. Rollerskating/rollerblading

hh.

Woodcarving/Wood working

f.

Boating/Canoeing

 

m. Eating

t. Horseback riding

bb. Ropes/Challenge course

ii.

Woodcutting/chopping

g.

Chores

 

 

n. Fighting

u. Martial arts

cc. Sleeping

z.

Other *

* Specify_____________________

2.Victim Information- (Complete for multiple victims)

Number of campers: male____ female____

Number of staff: male _____ female____

Number of others: male ______ female_______

DOH-61 (Abuse)

D.

SUPERVISION

 

 

 

 

1.

Supervision during incident (indicate as many as apply) _____ _____ _____ _____

 

 

 

 

a. Activity inadequately addressed in

d. No staff present

h. Staff orientation/training for activity not

k. Written plan not followed

 

the written plan

e. Quality of supervision adequate

 

documented/received

 

 

b. Activity not addressed in the written plan

f. Quality of supervision inadequate

i.

Supervision ratio inadequate

z. Other *

 

c. Camper orientation for activity not

g. Staff not trained/knowledgeable as

j.

Supervision ratio correct

* Specify____________________________

 

documented/received

per the written plan

 

 

___________________________________

E.

ALLEGED PERPETRATOR INFORMATION:

Attach additional sheets if multiple perpetrators.

 

Name: _______________________________________

Age:________

Sex ________

Information in shaded area is confidential

Status:

CIT/Jr. Counselor

Counselor

No relation to camp

Trespasser

Visitor

 

 

 

Camper

Dev. Disabled Camper

Other Staff*

 

Unknown

*Specify_________________________

F. INVESTIGATION

 

 

 

 

 

 

Was an On-Site investigation conducted by the Local Health Department?

Yes

No

Date of On-Site Investigation: ____/____/____

Did the Local Health Department conduct a telephone follow-up?

Yes

No

Date of Follow-up: ____/____/____

G.NARRATIVE- Do not include the full names of people involved with the incident. Use the first and last name initials or other similar code.

Allegation of Abuse- Provide a description of the event, conclusions and DOH recommendations: Include statements pertaining to Subpart 7-2 compliance and

the acceptability/implementation of the camp written plan. Recommendations should include whether or not administrative action against the camp will be taken as well as the steps that must be taken to prevent similar incidents in the future. See Environmental Health Procedure CSFP-142 for guidance in addition to completing this electronic report.

_______________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________

Information received by: _________________________________

Title:____________________________________

Report reviewed by: ____________________________________

Title:____________________________________

DOH-61 (Abuse)

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