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Indiana State Department of Health

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Communicable Disease

Fireworks Injury Reporting Form

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, 2 Selig
Indianapolis, IN 46204

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