Swimming Pool Incident Report Form
Injured person name
First Name
Last Name
Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Injured person gender
Male
Female
Age of the injured person
Date and time of the incident
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Specify the incident in detail
Nature of the incident
Please Select
Drowning
Near Drowning
Injuries
Fecal matter
Blood contamination
Vomit
What part(s) of the body was injured?
What caused the incident?
Location of incident
Main pool
Zero entry pool
Spa
Wading pool
Therapy pool
Diving board
Other
Water depth of incident
Was the pool/spa open in the time of incident?
Yes
No
Were lifeguards present?
Yes
No
Did the injured person go to the hospital?
Yes
No
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 Name
Last Name
Pool manager signature
Submit
Should be Empty: