Prevent Blindness America: Survey - Prevent Blindness America Fireworks Accident Registry

Prevent Blindness America Fireworks Accident Registry

Share Your Fireworks Story

Have you or has someone you know been injured by fireworks? By sharing your story with Prevent Blindness America, you can help spread the word about the dangers of fireworks.

1.

Please provide your background information.

*

Name:

First Required	Last Required

*

Email: Required

Street 1:

Street 2:

City/State/ZIP:

City	State	ZIP

Phone Number:

Employer:

Occupation:

Gender:

Yes, I would like to receive e-mail from Prevent Blindness America

Email Format:

Yes, I would like to receive postal mail from Prevent Blindness America

*2.

Question - Required - I am:

3.

Question - Not Required - If you described yourself as "other," please provide us with a brief description of your profession.

*4.

Question - Required - Please provide the age of the person who was injured.

*5.

Question - Required - Please provide the gender of the person who was injured. Male
Female

*6.

Question - Required - The firework involved was a: bottle rocket
sparkler
other

7.

Question - Not Required - If you answered "other," please tell us the type of firwork.

*8.

Question - Required - Please briefly explain the incident.

*9.

Question - Required - May we contact you to find out more about the accident?

10.

Question - Not Required - May we use your story in our materials to educate others about the dangers of fireworks?