Water Safety Survey
Client Name
*
First Name
Last Name
Date Survey Completed
*
/
Month
/
Day
Year
Date
Family Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
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Indiana
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Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Montana
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Nevada
New Hampshire
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New Mexico
New York
North Carolina
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Ohio
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Pennsylvania
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South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Family Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Staff Name
*
First Name
Last Name
Residential Water Hazards (check all that apply)
*
Pool
Spa/Hot Tub
Lake
Canal
Bathtub
Bucket
Other
*
Rows
Age of Child
Gender
Swim Lesson or Water Safety Education
Child
Male
Female
Yes
No
Child
Male
Female
Yes
No
Child
Male
Female
Yes
No
Child
Male
Female
Yes
No
Home Safety Measures in Place
Supervision
Constant adult touch supervision is used, not that of older children?
*
Yes
No
Does the adult supervisor(s) know how to swim?
*
Yes
No
During group gatherings, one adult is designated to supervise?
*
Yes
No
Only an adult supervises child during bath time?
*
Yes
No
Child is not left alone in the bathtub or around any water?
*
Yes
No
Swimming Pool Fence
Does the pool have a fence on all four sides?
*
Yes
No
NA
Does the fence isolate the pool from the house and the play area?
*
Yes
No
NA
All fence panels in place and securely attached?
*
Yes
No
NA
Climbable surfaces, including chairs, cushions away from fence?
*
Yes
No
NA
Fencing restricts child's access to lake, canal, for neighbor's pool?
*
Yes
No
NA
Swimming Pool Gate
Gate swings back to a closed position after being opened?
*
Yes
No
NA
Gate latches & remains securely closed on first swing?
*
Yes
No
NA
Around The Yard
Yard is free of objects to assist with climbing, such as chairs?
*
Yes
No
NA
Toys are always removed from the pool and stored out of view?
*
Yes
No
NA
Swimming Pool
Is the pool water clear?
*
Yes
No
NA
Pool area clear of electrical hazards?
*
Yes
No
NA
Is there a pool cover or net that supports the weight of 1 adult?
*
Yes
No
NA
Are pool chemicals/supplies locked in a secure area?
*
Yes
No
NA
Miscellaneous
Child resistant locks on all doors leading outside?
*
Yes
No
Are alarms on doors and windows leading outside?
*
Yes
No
Do sliding doors & screens have a safety mechanism or safety gate?
*
Yes
No
Is door screening intact so that a child cannot break/walk through?
*
Yes
No
Were door alarms provided to family?
*
Yes
No
Preparedness
Do the parents and caregivers know CPR with rescue breaths?
*
Yes
No
Parents know a submerged child must be removed from water?
*
Yes
No
Parents know to call (954) 357 - SWIM to learn about how and where to obtain swim lessons, swim coupon & water safety education information?
*
Yes
No
Submit
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