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
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 *
 
______________________________________________________________________________________________________
ACCIDENT INFORMATION
calendar
Activity at Time of Injury *
 
Where Accident Occurred *
 
Source of Injury *
 
______________________________________________________________________________________________________
FACILITY INFORMATION
Pool Type *
______________________________________________________________________________________________________
INJURY INFORMATION
Body Part Injured *
 
Symptom *
 
______________________________________________________________________________________________________
FIRST AID INFORMATION
On-site Care Given *
On-site Care Given By *
 
Type of Care Given on Site *
 
Care Refused by Injured *
Parent / Guardian Notified *
Taken to Hospital / Clinic *
______________________________________________________________________________________________________
CONTACT INFORMATION FOR TWO WITNESSES
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______________________________________________________________________________________________________
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.