Free 47400.FH11 - Indiana

REPORT OF INJURY / COMPLAINT OF INJURY
State Form 47400 (R / 6-08)

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PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 (317) 234-3031 www.IN.gov/pla

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 Address (number and street, city, state, and ZIP code) Name of operator on duty License number Telephone number

(

)

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:

No

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)