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Injured Person Background

Name of Injured Person

Date of Birth

Telephone Number

Address

City

State

Zip

Gender

Injury Details
Date and time of incident
Exact pool/location of incident
Nature of the incident

Describe in detail

What part of the body was injured? Describe in detail

Take photo of the body part that was injured. Annotate as required

What was the nature of the injury? Describe in detail

Take photo of the injury/source of blood contamination. Annotate as required

Describe fully how the accident happened?

What was the person doing prior to the event?

Take photo of the surrounding environment the person was in prior to the event

What caused the incident?

Add supporting evidence of contributing factors

Were safety regulations in place and used?

What was wrong?

Recommended preventive action to take in the future to prevent reoccurence

Witness Statements

Were there any witnesses?

Add witness

Witness

Enter witness name

Contact number

Witness statement

Witness signature
Emergency Services

Person went to doctor/ hospital?

Doctor's Name

Hospital Name

Police were called to the scene

Police reference number

Sign off
Injured person signature
Pool Operator/Manager signature

Swimming Pool Incident Report Template Checklist

Created by: SafetyCulture Staff | Industry: General | Downloads: 9

A swimming pool incident report template is used to record incidents such as injuries, vomit, fecal, blood contamination, near-drowning, drowning, or others. Use this template to record specific details of the incident and help the establishment improve safety and security measures.

Signup for a free iAuditor account to download and edit this checklist. It will be added to your free account and you will be able to conduct inspections from your mobile device.

Download and edit this free checklist

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Audit

Injured Person Background

Name of Injured Person

Date of Birth

Telephone Number

Address

City

State

Zip

Gender

Injury Details
Date and time of incident
Exact pool/location of incident
Nature of the incident

Describe in detail

What part of the body was injured? Describe in detail

Take photo of the body part that was injured. Annotate as required

What was the nature of the injury? Describe in detail

Take photo of the injury/source of blood contamination. Annotate as required

Describe fully how the accident happened?

What was the person doing prior to the event?

Take photo of the surrounding environment the person was in prior to the event

What caused the incident?

Add supporting evidence of contributing factors

Were safety regulations in place and used?

What was wrong?

Recommended preventive action to take in the future to prevent reoccurence

Witness Statements

Were there any witnesses?

Add witness

Witness

Enter witness name

Contact number

Witness statement

Witness signature
Emergency Services

Person went to doctor/ hospital?

Doctor's Name

Hospital Name

Police were called to the scene

Police reference number

Sign off
Injured person signature
Pool Operator/Manager signature