State of Oregon
Appendix C
Oregon Health Authority
Public Swimming Pool
Public Health Division
Accident / Drowning Report
Public Pool Program
800 NE Oregon Street, Suite 608
This report must be completed for every physician-
Portland, Oregon 97232-2162
treated accident or any drowning at a public swimming pool.
Phone (971) 673-0451 FAX (971) 673-0457
It is the responsibility of the pool operator to submit
the completed form promptly to the Oregon Health Authority, Public
Pool Program, 800 NE Oregon, Portland, OR 97232-2162
Date of Incident
Time:
Accident ID #
YY – MM - DD – Accession #
Official Use Only
Victim Information - Please do not identify the victim by name. If there are multiple victims
create a unique identifier for each victim
Unique Identifier
Victim’s Residence City or Town
State
Zip Code
Non-Swimmer:
Fatal Non-Fatal
SEX: M F
Age of Victim: (yrs)
Yes
No
Unk
Type of Injury: (Check all that Apply)
Possible Contributing Medical Condition? (Check all
Abrasion or Contusion Strain or Sprain
that apply)
Concussion
Fracture
Cardiac
Seizure
Stroke
Laceration
Other (Specify)________________________
Other (Specify)____________________________
Area of the Body Injured:
Treatment Required: (Check all that Apply)
No Treatment
First Aid
CPR ( Manual AED Oxygen )
Emergency Response? (Check all applicable
)
EMS
Police
Released to Parents for Followup
Not necessary
Pool Information
Pool License #________________
Name of Pool:
Address:
Number
Street
City:
State:
Zip Code
Contact Person:
Position:
Phone:
Was the pool open at the time?
Was a lifeguard on duty at the time?
Yes
No
Yes
No
If the victim was < 14 years old, was an adult supervising or
Who initially found the victim?
watching them?
Lifeguard
Family Member Pool Staff
Yes
No
Unrelated adult / child Other
Were they swimming alone (or no one was watching)?
Pool Open or Closed?
Yes
No
Open Closed
(Enclosure Secured Y N)
Did the lifeguard use their rescue tube?
How many staff were involved in the rescue? _______
Yes
No
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