Form Doh 61 is an important document for businesses and organizations with employees working in the United States. This form must be filed with the Department of Labor each year to report the total number of hours worked by all employees within a specific classification. Failing to file Form Doh 61 can result in fines and other penalties. Here we will provide an overview of what you need to know about Form Doh 61, including who needs to file it and what steps you need to take to complete it. Let's get started!
Question | Answer |
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Form Name | Form Doh 61 |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | camp alleg of abuse rptform environmental health manual procedure csfp 146 form |
NEW YORK STATE DEPARTMENT OF HEALTH |
Allegation of Abuse |
Bureau of Community Environmental Health and Food Protection |
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Children’s Camp Program |
Report Form |
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INSTRUCTIONS: See Environmental Health Manual Procedure |
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A. FACILITY INFORMATION |
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Facility Name:_____________________________________________________________________________________ Facility Code:____ _____ _____ ____ _____ _____ ____
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Facility Type: |
Day |
Overnight |
Municipal Day Camp |
Are 20% or more of the campers developmentally disabled? |
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Yes |
No |
Date Reported ____/___/____ |
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B. EVENT INFORMATION |
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eHIPS Incident |
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Note: If reportable injuries occurred as a result of this incident, complete an injury report form as well |
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Date of Incident ____/___/___ |
Time of Occurrence ____ :____ (Military time) |
Location where abuse occurred: ______ |
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a. |
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Where did injury occur? _____ |
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Specify for locations marked with an asterisk: _________________________________________________________ |
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a. Amusement park |
e. Arts & crafts |
i. |
Classroom |
m. Horseback area/trail |
q. |
Outdoor sports area |
u. |
Recreational hall |
y. Tenting/campsite area |
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b. Aquatic area* |
f. |
Assembly area |
j. |
Cookout area |
n. |
Indoor sports area |
r. |
Parking lot |
v. |
Riflery area |
z. Other* |
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c. Aquatic theme park |
g. Bathroom/shower k. |
Dining area |
o. |
Kitchen area |
s. |
Playground |
w. |
Ropes/challenge course |
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d. Archery area |
h. Camp/trail/road |
l. |
Drama/stage area p. |
Open field/lawn* |
t. |
Public highway/road |
x. |
Sleeping area |
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Nature of Allegation: |
___Physical Abuse |
___ Sexual Abuse |
___ Both Physical and Sexual Abuse |
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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
Age: _____ Sex: |
Female |
Male |
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Status: |
Camper |
Developmentally Disabled Camper |
CIT/Jr. Counselor |
Counselor |
Other Staff* |
Other* Specify _______________________________________ |
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What was the victim doing? ________ |
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a. Amusement park rides |
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h. Classroom instruction |
o. Free period |
v. |
Nature study/walk |
dd. Swimming |
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b. Aquatic theme park rides |
i. |
Cooking |
p. |
w. |
Playground equipment activity |
ee. Transportation |
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c. Archery |
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j. |
Court/field sports* |
q. Gymnastics |
x. |
Playing |
ff. |
Travel between activities |
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d. Arts & crafts |
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k. |
Dancing/Acting |
r. High adventure activity |
y. |
Riflery |
gg. |
Walking/Running |
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e. Bicycling |
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l. |
Diving |
s. Hiking |
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aa. Rollerskating/rollerblading |
hh. |
Woodcarving/Wood working |
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f. |
Boating/Canoeing |
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m. Eating |
t. Horseback riding |
bb. Ropes/Challenge course |
ii. |
Woodcutting/chopping |
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g. |
Chores |
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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_______ |
D. |
SUPERVISION |
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1. |
Supervision during incident (indicate as many as apply) _____ _____ _____ _____ |
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a. Activity inadequately addressed in |
d. No staff present |
h. Staff orientation/training for activity not |
k. Written plan not followed |
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the written plan |
e. Quality of supervision adequate |
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documented/received |
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b. Activity not addressed in the written plan |
f. Quality of supervision inadequate |
i. |
Supervision ratio inadequate |
z. Other * |
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c. Camper orientation for activity not |
g. Staff not trained/knowledgeable as |
j. |
Supervision ratio correct |
* Specify____________________________ |
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documented/received |
per the written plan |
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E. |
ALLEGED PERPETRATOR INFORMATION: |
Attach additional sheets if multiple perpetrators. |
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Name: _______________________________________
Age:________
Sex ________
Information in shaded area is confidential
Status: |
CIT/Jr. Counselor |
Counselor |
No relation to camp |
Trespasser |
Visitor |
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Camper |
Dev. Disabled Camper |
Other Staff* |
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Unknown |
*Specify_________________________ |
F. INVESTIGATION |
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Was an |
Yes |
No |
Date of |
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Did the Local Health Department conduct a telephone |
Yes |
No |
Date of |
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
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
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Information received by: _________________________________ |
Title:____________________________________ |
Report reviewed by: ____________________________________ |
Title:____________________________________ |