Swimming Pool Incident Report Form

Swimming Pool Incident Report Form
Injured person name
First NameLast Name
Phone number
Please enter a valid phone number.
Injured person gender
MaleFemale
Age of the injured person
Date and time of the incident
MonthDayYear
Date
Hour MinutesAM/PM Option
Specify the incident in detail
Nature of the incident
What part(s) of the body was injured?
What caused the incident?
Location of incident
Main poolZero entry poolSpaWading poolTherapy poolDiving boardOther
Water depth of incident
Was the pool/spa open in the time of incident?
YesNo
Were lifeguards present?
YesNo
Did the injured person go to the hospital?
YesNo
Hospital name
Results of the incident
Witness Information
Number of swimmers/witnesses during the incident
Witnesses' name and contact information
Pool Manager
Name of the pool manager
First NameLast Name
Pool manager signature
Clear
Should be Empty:

Witness Information