Report of Occurrence 2024

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.

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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 Non-athlete member

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
Facility Personnel	Athlete
Other Other

LSC * 🛈

Name of Club (enter UN if unattached) *

USA Swimming ID (if known)

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FACILITY INFORMATION

Facility Name *

Address *

City *

State *

Zip Code

Facility Type *

Indoor pool	Outdoor pool
Open water	Other location

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OUTCOME

Were parents / guardians notified *

Yes

No

N/A

Was care declined? *

Yes

No

Was 911 or emergency service called? *

Yes

No

Taken by ambulance? *

Yes

No

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ACCIDENT INFORMATION

Date of Accident * +

Type of Event *

Pool Meet *

Pool *

During Warm-up/warm down

Competition

During Warm-up/warm down *

Entry

Swimming during warm up/warm down

Exit

Competition *

Race start

Swimming during competition

Race finish

Race Start *

Bottom strike

Stepping on/off block

Backstroke ledge

Relay start

On Deck *

Officiating

Volunteering

Coaching

Participating as an athlete

Practice Camp *

Dryland

Practice in-water

Practice on-deck injuries

Practice other facility location

Dryland *

Stretching

Weight-lifting (includes medicine ball, TRX, etc. related activities)

Cardio conditioning

Practice in-water *

Entering pool (does not include racing starts)

Racing start practice

Swimming (no training equipment)

Exiting pool

Use of in-water training equipment

Open Water *

Travel (with team) *

To/from competition

To/from training camps

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INJURY INFORMATION

Injury severity (select only 1) *

Minor: no care on site or on-site first aid only

Medium: Needing follow up medical care (clinic, doctor, hospital)

Severe: needing extended care (broken bone, extended recovery)

Catastrophic: fatality, permanent disability (ex. blindness, paralysis, amputation)

Type of Injury or Health Event/Illness (select up to 2) *

Swimmer collision in water (2 athletes or more)

Swimmer collision with object in water (lane lines, pool bottom, wall, open water obstacles)

Slip/trip/fall

Crush injury

Struck by

Amputation

Extreme fatigue/overexertion

Environmental exposure

Health Event, Illnesses (ex. asthma, insect bites, non-physical injuries)

Body Part Injured (Select up to 2) *

Symptom/Type of Injury (Select up to 2) *

Description: Provide a description of 1) how the injury or health event/illness occurred and 2) the type of injury or health event/illness. *Please refrain from using personal names in this field. Use Athlete, Coach, Official, etc.) *

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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

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REPORT SUBMITTED BY

Name (submitted by) *

Contact Phone *

Email Address * 🛈

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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.