Swimming Incident Report Form – Fill Out and Use This PDF

The Swimming Incident Report form serves a critical role for public pool owners or operators in documenting any patron death, injury, or accident that necessitates an EMS response, an emergency room visit, or hospitalization. It requires detailed information about the facility, the owner, and the incident itself—ranging from the type of mishap to the actions taken afterwards. If you're responsible for a public swimming facility, ensuring you fill out this form accurately is essential for compliance and safety measures.

For a thorough and responsible handling of any such incident, click the button below to fill out the form.

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Swimming Incident Report Form PDF Details

The Swimming Incident Report form serves as an essential document for public pool owners or operators, designed to meticulously record the details of any significant incidents, such as patron deaths, injuries, accidents necessitating emergency medical services, emergency room visits, or hospitalization occurring within the facility's premises. This comprehensive tool aids in the formal reporting process by breaking down the necessary information into three main sections: Facility Information, Owner Information, and Incident Information. Each section requires specific details, including, but not limited to, the type of incident (such as drowning, immersion, cut/abrasion, among others), the day and time it occurred, the necessity of 911, ambulance, or emergency room services, and the person(s) involved. Additionally, it prompts for a description of the incident and subsequent actions taken, as well as an inquiry about the attachment of a police report. Aimed at ensuring compliance with health and safety standards, this form not only facilitates the effective communication of incidents to the concerned division but also emphasizes the importance of accountability and preventive measures in maintaining a safe recreational water environment. Moreover, it outlines a clear process for completion and submission, ensuring that incidents are recorded with precision and transmitted to the appropriate department for review and action, thus underscoring the joint responsibility of pool operators and regulatory authorities in safeguarding public health and safety.

Question	Answer
Form Name	Swimming Incident Report Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	25
Avg. time to fill out	10 min
Other names	swimming injury report form, DHEC, SC, swimming pool incident report

Form Preview Example

Swimming Pool

Incident Report

Compliance Assurance Division

* Please Type or Print Clearly

Section 1. Facility Information

Name :	Permit # :

Address :	County :

City, State, Zip :	Pool Type (circle one) : A B C D E F

Phone :

Section 2. Owner Information

Name :

Address :

City, State, Zip :

Phone Number :

Section 3. Incident Information

Type of Incident (circle one) :	a) Drowning	b) Immersion	c) Cut/Abrasion		d) Other

Date of Incident :			Time:

Was 911, Ambulence, or Emergency Room Visit Required (circle one) : YES				NO

Name of Victim :			Age :			Sex :

Witnesses

Name :		Age :

Name :		Age :

Description of Incident and Action Taken:












Police Report Attached (circle one) : YES	NO

Owner Signature:		Date:
		Date:

DHEC 3785 (07/01)

Purpose: This form is to be used by public pool owners or operators in the event of a patron death, injury, or accident requiring an EMS response, an emergency room visit, or hospitalization.

This application must be submitted to the following address:

SC DHEC

2600 Bull St.

Columbia, SC 29201

or faxed to: (803) 898-4215, Attn: Recreational Waters

ITEM BY ITEM INSTRUCTIONS FOR COMPLETING THIS FORM

SECTION 1. FACILITY INFORMATION:

In the left column of section 1, enter the FACILITY’s information including: name of facility, address, city, state, zip, and phone number.

In the right column of section 1, enter the FACILITY’s information including: permit number, county, and circle the pool type (A, B, C, D, E, F).

SECTION 2. OWNER INFORMATION:

In section 2, enter the FACILITY OWNER’s information including: name of facility owner, address, city, state, zip, and phone number.

SECTION 3. INCIDENT INFORMATION:

Circle type of incident (drowning, immersion, cut/abrasion, other). If other, please provide descriptive name.

In the left column enter the date of the incident. In the right column enter the time of the incident.

Circle (YES or NO) whether 911, ambulance or emergency room visit was required.

In the left column, enter the victim’s name. In the center column, enter the victim’s age. In the left column, enter the sex of the victim (male or female).

In the left column enter the names of witnesses to the incident. Enter the age of each witness in the right column.

Describe briefly the incident and any actions taken.

Circle (YES or NO) whether a police report is attached.

Owner sign and date the bottom of the form.

Office Mechanics and Filing: The form should be filed in the Recreational Waters File Room according to facility permit number.

DHEC 3785 (07/01)

How to Edit Swimming Incident Report Form Online for Free

When an incident occurs at a swimming pool, documenting every detail accurately and thoroughly is crucial for safety management and legal compliance. Follow this step-by-step guide to fill out the swimming pool accident report accurately.

1. Facility Information

Enter the facility's name, address, city, state, zip code, and phone number in the left column. In the right column, enter the facility's permit number and the county. You also need to circle the type of pool from the options provided (A, B, C, D, E, F), which classifies the pool based on specific characteristics.

Part no. 1 in filling in template incident report form swimming pool

2. Owner Information

In this section, input the facility owner's name, address, city, state, zip, and phone number. This part of the form establishes the responsible party for the facility.

3. Incident Information

Start by circling the type of incident, choosing from drowning, immersion, cut/abrasion, or other. If you select "other," provide a descriptive name for the type of incident. Next, enter the date and time of the incident in the respective columns.

Confirm whether a call to 911, an ambulance dispatch, or an emergency room visit was necessary by circling "YES" or "NO." Then, provide details about the victim — name, age, and sex. List any witnesses along with their ages in the spaces provided.

Finally, describe the incident and any actions taken succinctly in the designated area.

template incident report form swimming pool writing process outlined (stage 2)

4. Confirm Documentation

Check and circle whether a police report is attached, indicating "YES" or "NO." This field is essential for legal documentation and any potential follow-up that might be required.

5. Signature and Submission

The owner of the facility or the person responsible for the management of the pool must sign and date the bottom of the form. This confirms the accuracy and completeness of the information provided.