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INJURY / ILLNESS REPORT

State Form 46347 (R2 / 2-11)

INDIANA STATE DEPARTMENT OF HEALTH

Instructions:
Mail or fax form to:
Indiana State Department of Health
Environmental Public Health Division
2 North Meridian Street, 5E
Indianapolis IN 46204-3006
317/233-7811, Fax 317/233-7047
Rule 410 IAC 6-2.1 requires that for each occurrence that: results in death, requires resuscitation, results in transportation to a hospital or other facility for medical treatment, or results in an illness connected to the water quality at the pool be reported to the department within ten (10) days.
Please Print All Information. Facility Information
Name of Facility
Facility Identification Number
Street Address, City, State, ZIP Code
County
Contact Person (First, Last Name)
Telephone Number
Operator on Duty (First, Last Name)
Certified Pool Operator
Description of Incident
Date of Injury / Illness (mm/dd/yy)
Time of Day
Name of Person Affected (First, Middle Initial, Last Name)
Sex
Date of Birth (mm/dd/yy)
Street Address, City, State, ZIP Code
Telephone Number
Attending Physician (First, Middle Initial, Last Name)
Telephone Number
Was Facility Open for Swimming?
Was Resuscitation Required?
If Yes, then Performed by:
AED Device Used?
Result of Incident
If Death, Cause of Death:
Lifeguard Present?
How did injury Illness Occur? (attach additional sheets if needed):
Description of Injury
Type of Injury:
Area Injured (when other than Drowning or Near Drowning):
Where Did Injury Occur?
Description of Illness
Date of Onset of Symptoms (mm/dd/yy)
Number of Persons Affected:
Symptoms (check all that apply):
Signature:
Date: (mm/dd/yy)