State Form 47626 - Report Of Tanning Facility Inspection
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1REPORT OF TANNING FACILITY INSPECTION
State Form 47626 (R2 / 5-00)
INDIANA PROFESSIONAL LICENSING AGENCY
Inspections this licensing period
License number
302 West Washington Street, Room E034
Indianapolis, IN 46204
Name of facility
License
Withheld
Civil Penalties
Enforce
Location
Date (month, day, year)
County
Name of owner
Name of manager
Telephone number
Address (number and street)
(
)
Former owner and/or name
City and state
ZIP code
Number of devices
T elephone number
(
)
LICENSE:
EQUIPMENT CONSTRUCTION:
USERS INSTRUCTIONS:
Application Submitted
Design-
Electrical Safety
Provided by Manufacturer
Properly Licensed
Displayed
Mechanical Safety
Proper Access and
Available to Consumer
Support
Exposure Recommendations
NOTIFICATION:
LABEL REQUIREMENTS:
Contains Warning Label
Proper notice of new sunlamp products
Warning Statement - Danger
Instruction for Replacement Parts
Notification of changes in facilities/operating
Legible
Lamp Types
procedures
WARNING SIGNS:
Minimum Exposure Distance
Properly Located
Legible
CONSUMER PROTECTION:
How Measured
Proper Size
Properly Worded
Consumers Instructed
Exposures Limited
Warning - Protective Eyewear
Exposure Distance
Lamps
Filters
OPERATORS:
Warning - Maximum Exposure Time
Lamps Shielded
T emperature
Operators Trained
List Provided
Exposure Schedule
Time to Expect Results
Controlled
Emergency T elephone List
List Maintained
Misleading Statements
PROTECTIVE EYEWEAR:
DEVICE LABELS:
INJURY REPORT :
Adequate Number
Compliant
Manufacturer's Name and Address
Filed
48 Hours /
Telephoned
Eyewear Used
Month/Year manufactured
7 Days Written
Model/Type
Serial Number
Legible
SANITIZATION:
ADVERTISING:
CERTIFICATION LABELS:
Proper Sanitizer
Body Contact
No Safe or Free of Risk Claims
Provided
Legible
Surfaces Sanitized
Eyewear Sanitized
No Promotion of Unlimited Use
WRITTEN RECORDS
Sanitizer T est Kit
Single Use T oweling
Written Warning Statements
TIMER SYSTEM:
Assurance of Notification
Timers exceed maximum recommended
Signed
Visits Recorded
exposures
Exposure Times Recorded
Proper Timers
Records Kept Maintained
Graduations Consistent with Exposure Schedule
Customer Address, Telephone, Age Recorded
Timer Error Less Than 10%
PARENTAL CONSENT
Persons less than 18 years: written parental
TERMINATION CONTROLS:
consent provided
Consumer Termination Control
Persons less than 16 years accompanied by
Operator T ermination Control
parents
Approved
* Pending
Closed
Disapproved
Out of Business
Terminated
Remarks:
WARNING: The continued violation may result in the assessment of civil penalties.
Name of Inspector
Date received by owner/operator (month. day, year)
Date follow-up(month. day, year)
* Date of follow-up must be indicated.
DISTRIBUTION:
White - Professional Licensing Agency; Canary - Inspector; Pink - Tanning Facility
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