Casuarina Storm Accident/Incident Report Form
Injured person name
*
First Name
Last Name
Parent/Guardian name
*
First Name
Last Name
Contact number
*
-
Phone Number
Injured person gender
Male
Female
Age of the injured person
Date and time of the incident
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Specify the incident in detail
Nature of the incident
Please Select
Drowning
Near Drowning
Injuries
Fecal matter
Blood contamination
Vomit
What part(s) of the body was injured?
What caused the incident?
File Upload - please upload photos/documents if relevant.
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of
Location of incident
25m pool
pool grounds
change rooms
Other
Water depth of incident
Did the injured person go to the hospital?
Yes
No
Hospital name
Results of the incident
Witness Information
Number of swimmers/witnesses during the incident
Witnesses' name and contact information
Person reporting accident/incident
Name
First Name
Last Name
Signature
Submit
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