Date of incident: __ Time of incident: __

Name of individual responsible for incident: ____

Home Address: ____ Male ☐ Female ☐

City, AR, Zip: __ Phone: __

Did individual have any symptoms of illness at the time of incident? Yes ☐ No ☐

If yes, list the symptoms: ____

Nature of incident: ☐ Formed stool ☐ Diarrhea ☐ Vomitus ☐ Blood

Time of pool closure: ☐ AM/PM

Name of person in charge at the time of the incident ____ Is person in charge CPO certified? ☐ Yes ☐ No

Pool chemical readings at time of incident: Free Chlorine ☐ Combined Chlorine ☐ Total Alkalinity ☐ Cyanuric Acid ☐ pH ☐

Describe corrective action taken in sequence:

Specify chemical adjustments made:

Pool chemical readings at time of re-opening: Free Chlorine ☐ Combined Chlorine ☐ Total Alkalinity ☐ Cyanuric Acid ☐ pH ☐

Time of re-testing: ☐ AM/PM Time pool was reopened: ☐ AM/PM

Print Name / Title __ Date __

Signature of person completing report ____

Was matter reported to local health department? ☐ Yes ☐ No

Retain with permanent facility records