Naui Accident Report Form Page 3
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5GENERAL INFORMATION:
Type of incident: ___ Non-injury ___ Bodily injury ___ Fatality
Diving activity at time of incident: ___ Introductory dive experience
___ Receiving instruction ___ Sponsored group diving ___ Commercial diving
___ Other________________________________________________________
Victim was: ___ Scuba diving ___ Snorkeling ___ Other______________________________
Location of Incident: ___ Pool ___ Lake ___ Quarry ___ River ___ Ocean
___ Other___________________________________________________________
Describe location by country, state/province, county, and nearest geographic location.
________________________________________________________________________
Was there any apparent panic by victim? ___ YES ___ NO
Victim recovered: ___ On surface ___ Below, at depth of_________________________
indicate feet or meters
Length of time from incident/accident to recovery of victim?____________________________
Who made the rescue/recovery?_____________________________________________
Was rescue breathing attempted? ___ YES ___ NO
Was CPR attempted? ___ YES ___ NO If YES, by whom? _________________________
Was oxygen given? ___ YES ___ NO If YES, by whom? _________________________
Was an AED used? ___ YES ___ NO If YES, by whom? _________________________
Were emergency medical services used? ___ YES ___ NO
If YES, what agency?
________________________________________________________________________
Was victim transported to medical facility? ___ YES ___ NO
If YES, what facility?
________________________________________________________________________
Did the victim receive recompression treatment? ___ YES ___ NO
If YES, where?
________________________________________________________________________
Please attach a copy of any waiver, release or statement of understanding form. If the accident
took place during training, please attach copies of training records. If possible, attach a copy of
victim’s log book.
Do not provide this report to any other party.
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