20 CAR pt. 136, Appendix H
ENVIRONMENTAL HEALTH PROTECTION ENVIRONMENTAL HEALTH SERVICES REPORT OF ACCIDENT OR DROWNING AT POOLS, SPAS OR OTHER RELATED FACILITIES
Name of Facility: ____ Address: ____ City: _______
Name of Victim: ____ Address: ____ City: _______
Date of Incident: ____ Time: ______ am/pm Accident ☐ Drowning ☐ Fatality ☐
Description of water and weather conditions at time of the incident: _______
Name of employees involved in rescue attempt or treatment of injury: _______
Facility open at time of incident Yes ☐ No ☐ Lifeguard on duty Yes No Bather load: _______ ☐ ☐
VICTIM: Male ☐ Female Age: ___ Non-Swimmer Yes No ☐ ☐ ☐
FACILITY: Indoor ☐ Outdoor Spa Pool Water Slide Other (Specify): _______ ☐ ☐ ☐ ☐ ☐ ☐
Emergency telephone provided: Yes No
Type of lifesaving/first aid training of employees involved: _______
TYPE OF INJURY: Abrasion or contusion Concussion Fracture Laceration Strain or Sprain ☐ ☐ ☐ ☐ ☐ ☐ Other ☐ (Specify): _______
AREA OF BODY INJURED: Head Trunk Arm, hand or finger Leg, foot or toe ☐ ☐ ☐ ☐ ☐ Other ☐ (Specify): _______
DESCRIPTION OF INJURY: _______
Slippery Surface: Surrounding pool ☐ Bottom of pool ☐ Steps ☐ Other ☐ (Specify): _______
Deck Equipment: Ladders or handrails ☐ Lifeguard equipment ☐ Other ☐ (Specify): _______
Pool Enclosure: Inadequate ☐ Gate unlatched ☐ Horseplay involved ☐ Other ☐ (Specify): _______
Recirculation/Filtration Equip.: Mechanical ☐ Electrical ☐ Missing/broken equipment ☐
Other ☐ (Specify):
Diving, Jumping or Sliding: From board ☐ From poolside ☐ From slide ☐
Other ☐ (Specify): _______
Other: Swimming miscalculation ☐ Natural causes ☐ Use of alcohol ☐
Chemical or chemical related accident: Yes ☐ No ☐
If Yes, chemicals involved: _______
Brief description of accident: _______
Were police, rescue unit or other emergency personnel called: Yes ☐ No ☐
If Yes, list: _______
Brief description of emergency action taken on site: _______
Degree of treatment required: None ☐ CPR First aid Emergency room ☐ Hospital admission ☐ ☐ ☐
If necessary, make a sketch of the pool/spa area involved in the injury or accident
Additional remarks relevant to this accident: _______
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