Report of Occurrence 2023

USA Swimming Report of Occurrence

To be completed by coach / official / club or facility representative (not parent

or injured party). PLEASE REFRAIN FROM USING PERSONAL NAMES IN

THE ADDITIONAL DETAIL FIELDS. Indicate "athlete" or "swimmer" instead, as

in "swimmer slipped and fell on pool deck" or "athlete's knee was injured."

______________________________________________________________________________________________________

INJURED PARTY INFORMATION

First Name (legal) * 🛈

Last Name (legal) *

Address *

City *

State *

Zip Code *

Contact Phone (include area code) *

E-mail *

Gender *

Male

Female

Date of Birth (mm/dd/yyyy) *

Age at Time of Accident * 🛈

USA Swimming Member *

Yes

No

Membership Type *

Athlete

Coach

Official

Other

Is the injured athlete currently enrolled in Elite Athlete Health Insurance through the US Olympic Committee (N/A for non-athletes)? 🛈

Yes

No

Non-Member Type *

Guest/Spectator	Sibling
Parent	Volunteer
Other Other

LSC * 🛈

Name of Club (enter UN if unattached) *

USA Swimming ID (if known)

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ACCIDENT INFORMATION

Date of Accident * +

Activity at Time of Injury *

Meet - Competition	Meet - Warm-up
Meet - Warm Down	Meet - Entering / Pool
Meet - Watching / Observing	Meet - Walking
Practice - Entering / Exiting Pool	Practice - Dry Land
Practice - Other	Swimjitsu - Entering / Exiting Pool
Swimjitsu - Dry Land	Swimjitsu - Other
Other Other

Where Accident Occurred *

Water - Start End	Water - Turn End
Water - Side	Water - Bottom
Water - Lane Lines	Bleachers - Athlete's
Bleachers - Spectator's	Deck
Starting Blocks	Locker Room
Team Area	Hallway
Stairs	Gym
Outside Venue	Other Other

Source of Injury *

Slip / Trip / Fall	Struck Against / Ran Into
Lifting / Straining	Insect Sting / Bite
Foreign Body	Air Quality
Heat / Sun	Other Other

Provide Additional Details of Accident. Please refrain from using personal names in this field. Use Athlete, Official, Coach, etc. * 🛈

______________________________________________________________________________________________________

FACILITY INFORMATION

Facility Name *

Address

City *

State *

Zip Code

Swim Club Responsible for the Pool

Pool Type *

Indoor

Outdoor

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INJURY INFORMATION

Body Part Injured *

Head - Top	Head - Back	Head - Side
Head - Forehead	Face - Eye	Face - Ear
Face - Nose	Face - Mouth / Teeth / Lips	Face - Chin
Face - Cheek	Neck	Back
Chest / Stomach	Arm / Wrist	Hand / Finger
Leg	Knee	Ankle
Foot / Toe	Other Other

Symptom *

Cut	Bruise	Sprain
Concussion	Unconsciousness	Fracture
Dislocation	Swelling	Scrape
Shortness of Breath	Vomiting	Burn
Seizure	Other Other

Addtional Details of Injury 🛈

______________________________________________________________________________________________________

FIRST AID INFORMATION

On-site Care Given *

Yes

No

On-site Care Given By *

Coach	Parent
EMT / Paramedic	Facility Staff
Trainer	Lifeguard
Other Other

Type of Care Given on Site *

Ice	Immobilized	Bandage
Cleaned	Other Other

Name of Person Giving Care 🛈

Care Refused by Injured *

Yes

No

Parent / Guardian Notified *

Yes

No

Taken to Hospital / Clinic *

Yes

No

Unknown

Hospital / Clinic Name *

Hospital / Clinic Location *

______________________________________________________________________________________________________

CONTACT INFORMATION FOR TWO WITNESSES

Name (witness one)

Address

City

State

Zip Code

Phone

..........................................................................................................................................................................................................

Name (witness two)

Address

City

State

Zip Code

Phone Number

..........................................................................................................................................................................................................

Activity / Meet Supervisor

Contact Phone

______________________________________________________________________________________________________

REPORT SUBMITTED BY

Name (submitted by) *

Contact Phone *

Email Address * 🛈

______________________________________________________________________________________________________

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.