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."  
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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
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
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
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
Source of Injury *
 Slip / Trip / Fall
 Struck Against / Ran Into
 Lifting / Straining
 Insect Sting / Bite
 Foreign Body
 Air Quality
 Heat / Sun
 Other
Additional Details of Accident
 
 
 
 
 
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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
Symptom *
 Cut
 Bruise
 Sprain
 Concussion
 Unconsciousness
 Fracture
 Dislocation
 Swelling
 Scrape
 Shortness of Breath
 Vomiting
 Burn
 Seizure
 Other
Addtional Details of Injury
 
 
 
 
 
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FIRST AID INFORMATION
On-site Care Given *
 Yes
 No
On-site Care Given By *
 Coach
 Parent
 EMT / Paramedic
 Facility Staff
 Trainer
 Lifeguard
 Other
Type of Care Given on Site *
 Ice
 Immobilized
 Bandage
 Cleaned
 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 *
 
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CONTACT INFORMATION FOR TWO WITNESSES
Name (witness one)
 
Address
 
City
 
State
 
Zip Code
 
Phone
 
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Name (witness two)
 
Address
 
City
 
State
 
Zip Code
 
Phone Number
 
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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.