Incident Description

Short description of incident.

Date of Incident

YYYY

Time of Incident

Hour

Minute

Second

Location of Incident

Provide the address of the location and it's description (pool, deck, house, street, etc.)

Instructor Name

First Name

Last Name

Client Name

First Name

Last Name

Name of Person/s Injured

Injured Person:

Bodily Injury

Please describe in detail any injuries sustained during the incident.

Description of Events

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.

Emergency Medical Treatment Provided

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.

Emergency Medical Services Provided by Instructor

Describe all treatment provided by instructor (Ex: Water Rescue, First Aid, CPR/AED, etc.)

Was the injured person taken to the hospital?

Yes

Name of Hospital

If not applicable, write N/A

Were Police called to the scene?

Yes

Name of Police Department and Officer

If police were not called, write N/A.

How did you handle the situation?

Describe the steps you took to control the situation.

Could you have done anything better?

Any other information we should know:

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