Form 47400 - Report Of Injury / Complaint Of Injury

Download a blank fillable Form 47400 - Report Of Injury / Complaint Of Injury in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 47400 - Report Of Injury / Complaint Of Injury with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Reset Form

PROFESSIONAL LICENSING AGENCY

REPORT OF INJURY / COMPLAINT OF INJURY

402 West Washington Street, Room W072

Indianapolis, Indiana 46204

State Form 47400 (R / 6-08)

(317) 234-3031

NOTE:

IC 16-1-47, Section 18 (A) the operator of a tanning facility must report each known: (1) injury; or (2) complaint of an injury; that results from the use

of a tanning device in the tanning facility to the State board.

IC 16-1-47, Section 18 (B) requires this report to be mailed to the Professional Licensing Agency within seven (7) days after the injury. In addition,

the law requires the operator to telephone the report to the Professional Licensing Agency within forty-eight (48) hours after the injury or complaint of

injury. Copies of this report will be mailed to the injured / complaining person and to the federal Food and Drug Administration.

FACILITY INFORMATION

Name of facility

License number

Address (number and street, city, state, and ZIP code)

Telephone number

(

)

Name of operator on duty

INJURY INFORMATION

Date of injury (month, day, year)

Name of person injured

Address (number and street, city, state, and ZIP code)

Type of injury

Duration of tanning exposure

Was medical attention needed?

Name of attending physician

Yes

Treatment (at tanning facility):

Treatment (at medical facility):

Comments:

I certify that I personally completed this report and that the information hereon is true and correct to the best of my knowledge and belief. I understand

that providing fraudulent information may be grounds for disciplinary action against the license of this facility.

Signature of owner or manager

Date (month, day, year)