When circumstances lead to an injury or incident, especially those occurring within facilities that necessitate immediate attention from medical professionals or, in dire situations, lead to drownings, the Indiana State Department of Health requires the use of State form 46347. Designed to streamline the process of reporting such unfortunate events, this form plays a crucial role in ensuring a swift response from both the Indiana State Department of Health and local health departments. Facilities must complete and mail this form within ten days of the incident, providing detailed information about the facility, the operator on duty, and comprehensive details about the person affected—including the nature of the injury and any medical attention received. This structured approach aids in monitoring and responding to health-related incidents at a state level, underscoring the commitment to public safety and health. Furthermore, the form serves as a vital piece of documentation, requiring the signature of the reporting individual, thus ensuring accountability and accuracy in the reporting process.
| Question | Answer |
|---|---|
| Form Name | State Form 46347 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | injury indiana injuryincident report form |
INDIANA STATE DEPARTMENT OF HEALTH
INJURY /INCIDENT REPORT
State form 46347
Instructions: 1. Mail form to:
State Department of Health
2 North Meridian Street, 5E
Indianapolis IN
Rule 410 IAC
FACILITY INFORMATION
Name of Facility _____________________________________________ ID# _________________
Address _________________________________________ Phone No._______________________
________________________________________________ County __________________________
Operator on Duty _____________________________________________ CPO* ____Yes _____ No
*Certified Pool Operator
PERSONAL INFORMATION
Date of Injury/Accident ______________________________________________________________
Name of Person Affected ____________________________________________________________
Address _________________________________________________________________________
City __________________________ State ____________________ Zip _____________________
Did Death Occur? ________________ Cause of Death ___________________________________
Type of Injury _____________________________________________________________________
Attending Physician _________________________________________ Phone # _______________
Treatment at the Pool _______________________________________________________________
Treatment at a Medical Facility _______________________________________________________
Comments _______________________________________________________________________
Date: _________________________ |
Signature: ______________________________________ |