Swimming Incident Report Form PDF Details

This template is created for public pool owners or operators to document significant incidents involving pool patrons. Such incidents include injuries, accidents requiring emergency medical response, or hospitalization. The swimming incident report form is structured to capture all relevant details:

- Date and time of the incident.

- The location of the incident within the pool area.

- Details of the incident, including a thorough description of what happened.

- Names and contact information of any witnesses.

- Actions responding to the incident, such as first aid or emergency services involvement.

- The outcome of the incident, including any medical care provided.

- Follow-up actions recommended to prevent future occurrences.

It helps in documenting details about incidents like injuries, near-drownings, equipment malfunctions, or any safety hazards. This form records the specifics of an incident and provides data that can be analyzed to improve pool safety and prevent similar incidents in the future.

In the case of legal action or insurance claims, having detailed and formal documentation of the incident is also invaluable. A swimming pool incident report gives a clear, chronological account of what happened, supporting the facility’s position and helping in the fast resolution of claims.

QuestionAnswer
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:

 

 

 

 

 

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.