New Jersey Department of Health

BODY ART INFECTION/INJURY REPORT

Copies of the Body Art Infection/Injury Report forms must be mailed to the Department of Health in January of each year!

SECTION I - INFORMATION ON LOCAL HEALTH DEPARTMENT RESPONDING TO REPORT
Name of Local Health Department

Address, City, State, Zip Code

Name of LHD Official Receiving Report

Telephone No.

Fax No.

SECTION II - INFORMATION REPORTED BY BODY ART ESTABLISHMENT
1. Date Incident Reported by Victim

2. Name of Person Reporting Incident

3. Time Incident Reported

4. Name of Artist

5. Name and Address of Body Art Establishment (where procedure was performed)

6. Business Telephone No.

7. Parent or Legal Guardian’s Signed Consent for Procedure to be Performed (if victim is a minor):

Fax copy to Local Health Department	8. Client’s Application and Aftercare Instructions:

Fax copies to Local Health Department

9. Name of Victim (Last, First, MI)

10. Date of Birth

11. Street Address

12. Home Telephone No.:

13. City, State, Zip Code

14. Business Telephone No.:

15. Date of Procedure

16. Time of Procedure

17. Sex

Male Female
18. Race

White Black Hispanic Asian/Pacific Islander Other Don’t Know
19. Did the victim’s health history list any of the following medical conditions?
Diabetes Allergies Skin Conditions Medications Other:
SECTION III -INVESTIGATION

A - INTERVIEW WITH VICTIM
20. Date of Interview

INTERVIEWER’S INSTRUCTIONS:

Read everything to the individual being interviewed and check all appropriate answers.

INTERVIEWER’S SCRIPT:

Hello! I am ____________________ with the ______________ Health Department and we are working with the New Jersey Department of Health to identify risk factors for infections or injuries which may have resulted from a body art procedure. We are trying to determine the cause so that we can prevent any future problems. I need about 15 minutes of your time.

If answer is YES -- Skip to “Information on Victim.”

If answer is NO -- is there a better time when I can call?

Day:	Date:	Time:	AM PM
If answer is NO, also state the following: It is really important that we find out what is causing this problem. All your answers will be kept confidential, and I will try to keep this interview as short as possible.

If answer is still NO -- Thank you for your time!

BODY ART INFECTION/INJURY REPORT, CONTINUED

B - INFORMATION ON VICTIM
INTERVIEWER’S SCRIPT:

First, I would like to obtain some basic information (continue with questions).

21. What kind of work do you do?
Office	Service	Construction	Professional	Student	Other:
22. Did you stop working as a result of your infection/injury?

Yes No	23. If Yes, what date did you return to work?

24. Did you do any of the following within one month after the procedure?
a.	Did you go on vacation after the procedure?	Yes No
If Yes, where did you go?
b.	Did you go swimming after the procedure?	Yes No
c.	Were you on the beach after the procedure?	Yes No
d.	Were you in the sun after the procedure?	Yes No
e.	Were you involved in any sports/physical activities after the procedure?	Yes No
If Yes (items a through e) explain:
C - INFORMATION ON THE PROCEDURE
INTERVIEWER’S SCRIPT:

Now I would like to ask you some questions related to the body art procedure.

25. What Body Art procedure was performed?

Tattoo	Permanent Cosmetics	Ear Piercing
26. On what part of the body was the procedure performed?

Nose	Tongue	Ear Lobe	Hand	Back

Lip	Face	Nipple	Arm	Abdomen

Eyebrow	Trailing Edge of Ear	Navel	Foot	Other:
Eyelid	Upper Outer Edge of Ear	Genitals	Leg
27. How long did the procedure take?

Less Than 1 Hour 1 to 2 Hours 2 to 3 Hours Greater Than 3 Hours
28. Type of jewelry artist used (gold, silver, etc.):

29. Did you receive after care instructions from the artist?

Yes No
30. Did you notify the artist of your medical problem?

Yes No	31. If Yes, date you notified the artist of your medical problem:

D - MEDICAL AND TREATMENT INFORMATION
Now I would like to ask you some questions about your skin reaction or infection. Please answer Yes if you have had any of the following symptoms. (Note: Refer all outstanding medical issues to a physician.)

32. Did your physician confirm any of the following?

Inflammation	Lesions	Headache	Vomiting

Fever	Allergic Reaction	Anorexia	Jaundice

Pain	Keloids	Rash	Blurred Vision
Warts	Malaise	Nausea	Other:
33. What date did the first symptoms appear?

34. Were you taking any medications prior to the procedure?

No Yes-Name of Medication:
35. Were you admitted to a hospital, emergency clinic or emergency room?	Yes No
a. What hospital?
b. Location:
c. Admission Date:	d. Telephone No.:

BODY ART INFECTION/INJURY REPORT, CONTINUED

D - MEDICAL AND TREATMENT INFORMATION, CONTINUED
36. Did you see a physician or other health care professional for this skin reaction or infection?	Yes No
a. Name of physician or health care professional:
b. Address:
c. Date Seen:	d. Telephone No.:
37. Did the physician give you any medications?

Yes No

If Yes, -Name(s) of Medication:

38. Did you have any blood work done as a result of this incident?

Yes No

If Yes, what was it for:

HIV HBV Both
Other:
39. Did your physician or health care professional confirm a diagnosis?

Yes No If Yes, what was the diagnosis?

Keratoconjunctivitis	Pyogenic	Corneal Abrasion	Chipped Tooth/Teeth

Cellulitis	Impetigo	Allergic Reaction to Pigments/Dyes	Loss of Eyelashes

Staphylococcal	Eczema	Allergic Reaction to Latex	Ectropion

Streptococcal	Viral Hepatitis	Pigment Migration	Entropion
Other (be specific):
40. What were the results of laboratory tests?

E - FOLLOW-UP ACTION BY INVESTIGATOR
41. Date of Last Inspection

42. Was an investigation conducted as a result of this Infection/Injury Report?

Yes No N/A

If Yes, date of investigation:

If Yes, provide comments below:
43. Was enforcement action taken?

Yes No N/A

If Yes, date of enforcement action:

If Yes, provide comments below:
44. Comments:

EHS-36

JUL 12	Page 2 of 3 Pages.

_________________________________________________________________________________________

EHS-36, Body Art Infection / Injury Report

environmental health services, public health sanitation and safety, body art, tattoo, injury, infection, report, EHS-36

Elaine White

2002-11-01

ewhite

NJDOH