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Information for Emergency Medical Services Providers and Employers
Instructions for Completing the Notification of Blood or Body Fluid Exposure
Emergency Medical Services Provider State Form Number 51467 (9-03)
Smallpox Vaccine Injury Compensation Program
Notification of Blood or Body Fluid Exposure
Download the Fireworks Injury Reporting Form (State Form 51497) and either Fax or mail to the Indiana State Department of Health.
Fireworks Injury Reporting Form
Please fax this form to (317) 233-7761; Attn: Injury Epidemiologist
Or mail to: Indiana State Department of Health
2 North Meridian Street, 6A
Indianapolis, IN 46204
Please direct any calls to (317) 234-6325
NOTE: DO NOT FAX Case Report Forms; completed Case Report Forms should be mailed to:
Office of Clinical Data and Research
Indiana State Department of Health
2 N. Meridian St., 6-C
Indianapolis, IN 46204
ADULT FORM (>13 years of age at time of diagnosis)
PEDIATRIC FORM (<13 years of age at time of diagnosis)
Link to Communicable Disease Rule: PDF
Link to Indiana Reporting Law: http://www.ai.org/legislative/ic/code/title16/ar41/ch2.html#ic16-41-2-1
Link to Instructions for filling out an Adult Confidential Case Report form, and highlighting
the new areas of the form: Microsoft PowerPoint Presentation
OR PDF Version
The Indoor and Radiologic Health (IRH) program has two laws and two regulations that govern its activities: