Do you have old state forms collecting dust in your filing cabinet? If you own a business, chances are that one of those musty documents is State Form 46347. This form may not seem like much to the untrained eye, but it plays an important role in ensuring compliance with tax regulations. Whether you’re creating this document for the first time or need help understanding its specific requirements, we’ll walk you through how to complete and file State Form 46347 correctly.
| 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: ______________________________________ |