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Swimming Pool Incident Report Template

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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.
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Rated 4.8/5 stars on Capterra
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Swimming Pool Incident Report Template

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

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