Public Swimming Pool Accident / Drowning Report

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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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