Short description of incident.
Date of Incident *
Date of Incident
Time of Incident *
Time of Incident
Provide the address of the location and it's description (pool, deck, house, street, etc.)
Instructor Name *
Instructor Name
Client Name *
Client Name
Please describe in detail any injuries sustained during the incident.
Please describe EXACTLY what happened. This should be an in-depth description and timeline of events that occurred during the incident. This description may be used in any subsequent legal proceedings.
Was 911 called? Describe (to the best of your abilities) any treatments provided by Fire, Police or Paramedic/EMT. If EMS was not contacted, write N/A.
Describe all treatment provided by instructor (Ex: Water Rescue, First Aid, CPR/AED, etc.)
Was the injured person taken to the hospital? *
If not applicable, write N/A
Were Police called to the scene? *
If police were not called, write N/A.
Describe the steps you took to control the situation.