Firearm Injury Report Form - State of Alaska, Section of Chronic Disease Prevention and Health Promotion

1. Reporter details

Per 7 AAC 27.013, health care providers are required to report all injuries caused by a firearm to the Division of Public Health. Reports must be made within 5 working days of the date of diagnosis. Forms and definitions may be found at: https://health.alaska.gov/en/services/report-condition/

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* Reporting Agency

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* Agency Phone Number

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* Agency Record Number

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