Incident Report
Wake Aquatic Partners Incident Reporting Form
Facility Name
*
Date & Time of Incident
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Incident Type
*
Please Select
Active/Distressed Rescue
Facility
Medical
Pool Closure
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Guest Contact Information
Patient Name
*
First Name
Last Name
Age of Patient
*
-
Month
-
Day
Year
DOB
Patient Gender
*
Please Select
Female
Male
Other
Guest Status
*
Please Select
Facility Member
Facility Guest
Team Member
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Medical Incident Information
Describe the Incident
What Happened?, How It Happened?, etc.
Describe the Injured Party's Condition
Location of Injury on Person, Symptoms, Etc.
Who Provided Care?
First Name
Last Name
Describe the First Aid Provided
Was There Any Blood-Borne Exposure?
Yes
No (PPE Precautions Taken)
Was 911 Called?
Yes
No
Was the Injured Person Transported?
Yes
No
Declined
Where were they Transported?
Was a Parent/Guardian Present at the Time of the Incident?
Yes
No
When and Who was Contacted?
Witnesses
List All Witnesses. Indicate whether they are a member, guest, or team member and a contact phone number.
Is a Follow-Up Required?
Yes
No
When is the Follow-Up Date?
-
Month
-
Day
Year
Date
Who will complete the Follow-Up?
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Facility Incident Information
Pool Name
Main Pool, Baby Pool, etc.
Reason for Closure
Planned Reopen Time
Hour Minutes
AM
PM
AM/PM Option
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Time Incident Report was Written
*
-
Month
-
Day
Year
Auto Populated
Time Minutes
AM
PM
AM/PM Option
Lifeguard who Performed Rescue?
Location of Rescue
Team Member Filling Our Report
*
First Name
Last Name
Team Member Position
*
Attendant, Lifeguard, Lifeguard Manager, etc.
Submit
Should be Empty: