Public Swimming Pool Accident Drowning Report Mobile App

Included Fields

Customize to add, remove, or edit any of the fields below.

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  This report must be completed for every physician- treated accident or any drowning at a public s...

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  Date of Incident

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  Time:

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  First Name

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  MI

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  Last Name

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  Address

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  City or Town

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  State

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  Zip Code

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  SEX

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  Age of Victim:(yrs)

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  Non-Fatal

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  Fatal

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  Non-Swimmer:

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  Area of the Body Injured: (Check all that Apply)

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  Head

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  Arm / Hand / Finger

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  Trunk

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  Leg / Foot / Toe

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  Other (Specify)

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  Type of Injury: (Check all that Apply)

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  Abrasion or Contusion

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  Concussion

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  Strain or Sprain

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  Fracture

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  Laceration

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  Other (Specify)

• ...and More!