Public Swimming Pool Accident / Drowning Report (Page 2 of 2) in pdf

Public Swimming Pool Accident / Drowning Report Page 2

Side 2 of 2

Factors contributing to the accident (Mark as many as apply)

 Around Pool

 Bottom of Pool

 Other (Specify)

Slippery Surfaces:

 Ladder / Handrails  Lifeguard Equipment

 Other (Specify)

Deck Equipment:

 Mechanical

 Electrical

 Other (Specify)

Recirculation Equipment:

 Storage

 Handling

 Other (Specify)

Use of Pool Chemicals:

 Inadequate

 Gate - Unlatched or Unlocked

 Other (Specify)

Pool Enclosure:

 From Board  From Poolside  From Slide  Other Specify

Diving/Jumping/Sliding:

Horseplay/ Miscalculation:

(Specify)

Other: (Explain)

Were Others Injured:  Yes

 No

If Yes, Please Supply Accident Report Identifiers: ___________________________________________________

Describe what happened: (Please be legible)

Use “victim,” “bather,” “swimmer,” etc. No victim or parent names. Naming of rescuers, witnesses or

others may be appropriate. Do not attach EMS, police or insurance reports in lieu of filling this section

out. Other reports adding information are appropriate, but may be disposed of after review to protect the

injured party’s personal information.

Signature:

Print or Type Name:

Date:

PHD 100 (rev 7/8/2013)

Public Swimming Pool Accident / Drowning Report Page 2