Swimming Pool Incident Report Template

• Name of injured person

• Conducted on

  Date

• Prepared by

• Location
  Address

Injured Person Background

• Name of Injured Person

• Date of Birth

  Date

• Telephone Number

• Address

• City

• State

• Zip

• Gender

  Male

  Female

Injury Details

• Date and time of incident

  Date
• Exact pool/location of incident
  Address

• Nature of the incident

  Select Injuries Vomit Fecal matter Blood contamination Near-drowning Drowning Others

  • Injuries
  • Vomit
  • Fecal matter
  • Blood contamination
  • Near-drowning
  • Drowning
  • Others

• 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

  Media

• What was the nature of the injury? Describe in detail

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

  Media

• 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

  Media

• What caused the incident?

• Add supporting evidence of contributing factors

  Media

• Were safety regulations in place and used?

  Yes

  No

  N/A

• What was wrong?

• Recommended preventive action to take in the future to prevent reoccurence

Witness Statements

• Were there any witnesses?

  Yes

  No

• Add witness

Witness

• Enter witness name

• Contact number

• Witness statement

• Witness signature

  Sign

Emergency Services

• Person went to doctor/ hospital?

  Yes

  No

• Doctor's Name

• Hospital Name

• Police were called to the scene

  Yes

  No

• Police reference number

Sign off

• Injured person signature

  Sign

• Pool Operator/Manager signature

  Sign