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Revised 10/15/2018 A full report of specific injuries or illnesses occurring as a result of using an ultraviolet radiation (tanning) device shall be made by the operator to the Permit Issuing Official (PIO) within twenty-four (24) hours of notification of its occurrence. Reportable injuries and illnesses shall include: all eye injuries requiring medical attention; all burns requiring medical attention; any other injury or illness incident resulting from the use of an ultraviolet radiation device for which medical care has been obtained. Forms shall be maintained at the tanning facility for a minimum of two years and must be available for review by the PIO. Facility Information Facility Name: Name of Operator: Facility Address: Facility Telephone Number: Type of Facility: □ Tanning Only □ Salon/Spa □ Fitness □ Other Client Information Name (Last, First, Middle): Home Address: Telephone Number: Age (years): Gender: □ Female □ Male Tanning frequency (3 month history): □ First time tanning □ Between 2 and 9 sessions □ 10 or more sessions Event Information Specific injury or illness requiring medical attention: □ Eye injury □ Burn □ Any other injury or illness incident Date of incident/onset: Time of occurrence/onset: □ AM □ PM Location where incident occurred: □ Tanning Bed □ Tanning Booth □ Duration of tanning exposure: Nature of incident: Date client reported incident: Time client reported incident: □ AM □ PM Name of medical provider: Date of medical treatment: Reported diagnosis/treatment: Follow up for incident: Equipment Information Manufacturer of the tanning device: Date of manufacture: Model: Model Number: Serial Number: Types of lamps used in the tanning device: Information received by: Title: Date: New York State Department of Health Bureau of Community Environmental Health and Food Protection Tanning Facilities Program Injury and Illness Report Form Incident Log Number: Area(s) of injury: □ Acute illness or disease* □ Chronic illness or disease* □ Allergic reaction* □ Dehydration □ Anaphylactic shock* □ Infection* □ Cardiac □ Other* *Specify: □ Head □ Arm □ Chest □ Leg □ Face □ Wrist □ Abdomen □ Ankle □ Eye □ Hand □ Back □ Foot □ Neck □ Finger □ Shoulder □ Other, specify: Description of illness: