USA Swimming Report of Occurrence

INSTRUCTIONS

To be completed by USA Swimming:

  • Coach
  • Official
  • Club designated personnel

Complete a Report of Occurrence for injuries or medical incidents involving USA Swimming members and non-members occurring during a USA Swimming activity. The report should be completed as soon as possible, at least within 24 hours after the occurrence.

If the occurrence involves serious injury (example: fatality, multiple individuals, life-threatening event), please notify your Team Services member or USA Swimming at 719-217-4796.

______________________________________________________________________________________________________
INJURED PARTY INFORMATION
Gender *
USA Swimming Member *
Membership Type *
Is the injured athlete currently enrolled in Elite Athlete Health Insurance through the US Olympic Committee (N/A for non-athletes)? 🛈
Non-Member Type *
 
______________________________________________________________________________________________________
FACILITY INFORMATION
Facility Type *
______________________________________________________________________________________________________
OUTCOME
Were parents / guardians notified *
Was care declined? *
Was 911 or emergency service called? *
Taken by ambulance? *
______________________________________________________________________________________________________
ACCIDENT INFORMATION
 +
Type of Event *
Pool Meet *
Pool *
During Warm-up/warm down *
Competition *
Race Start *
On Deck *
Practice Camp *
Dryland *
Practice in-water *
Open Water *
Travel (with team) *
______________________________________________________________________________________________________
INJURY INFORMATION
Injury severity (select only 1) *
Type of Injury or Health Event/Illness (select up to 2) *
Body Part Injured (Select up to 2) *
Symptom/Type of Injury (Select up to 2) *
______________________________________________________________________________________________________
CONTACT INFORMATION FOR TWO WITNESSES
.......................................................................................................................................................................................................... 
.......................................................................................................................................................................................................... 
______________________________________________________________________________________________________
REPORT SUBMITTED BY
______________________________________________________________________________________________________

Click the SUBMIT button when you have completed the form. You will receive an e-mail copy of your submission. Please forward it to the appropriate Safety Chair for your LSC.