<p> ACCIDENT/INCIDENT REPORT FORM</p><p>Date of incident: ______Time: ______AM/PM</p><p>Type of Incident (Circle one): Facility Emergency Weather Emergency Accident/Injury Fire/Chemical Emergency Drowning Spinal Injury Details of incident: </p><p>Actions Taken: </p><p>For injury reporting only:</p><p>Name of injured person: Address: Phone Number(s): Date of birth: ______Male ______Female ______</p><p>Who was injured person? ______</p><p>Injury requires physician/hospital visit? Yes ___ No _____ Name of physician/hospital: Address: Physician/hospital phone number: </p><p>Signature of injured party ______Date *No medical attention was desired and/or required.</p><p>Signature of injured party Date</p><p>Return this form to Safety Chair within 24 hours of incident.</p><p>0a12db9e20458d2fba28da7f4507794c.doc 1 3-Aug-17 ACCIDENT/INCIDENT REPORT FORM USA Diving or USA Swimming Incident forms must be fill out within 3 hours of the incident and filed with USA Diving or USA Swimming respectively.</p><p>0a12db9e20458d2fba28da7f4507794c.doc 2 3-Aug-17</p>