SUBMERSION INCIDENT REPORT

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					                                                 SUBMERSION INCIDENT REPORT
                                                                  FOR ALL DROWNING OR NEAR DROWNING
                                                                                 INCIDENTS IN CLARK COUNTY
                                                          Fax completed form to SNHD EMS Office at: 702-383-1240
                                                                                   For questions call: 702-759-1050

            BASIC INCIDENT INFORMATION                                           A: ADULT SUPERVISION
Date of Incident:         Time of Incident:                      Age of Supervisor(s) at time of incident:      Unknown
Your Agency’s Incident Number:                                            Mother               Father
Reporting Agency:                                                         Sibling              Babysitter/Childcare Provider
Incident Location City/Zip:                                               Other (specify):

Type of Dwelling:         House         Apartment/Condo          Supervisor activity immediately prior to incident:
  Hotel/Motel             N/A           Other:                                                              Unknown
                 VICTIM INFORMATION                              Alcohol and/or drug use evident?       Yes    No     Unknown
Age of Victim:                   Sex:     M         F
Victim’s Race/Ethnicity:     Unknown                                           B: BARRIER INFORMATION
  Hispanic      White     Black     American Indian              Barriers Present Around Water:        Unknown       None
  Asian/PI      Other:                                             Property Perimeter Fence        Isolation Pool Fence
Victim Last Seen:      Unknown                                      Fence Type:                     Fence Type:
  Swimming             Playing Outside    Playing Inside            Fence Height:                   Fence Height:
  Sleeping             Other:                                      Self-closing/Self-latching gate
                                                                    Gate working properly?         Yes No Unknown
Est. Time of Submersion:                  Unknown
                                                                   Door/Window Alarm               Approved pool safety cover
Type of Clothing Worn by Victim:       Unknown                     Pool Safety Net                 Self-closing doors on house
  Swim suit        Day clothing        Pajamas                     Perimeter pool alarm            In-Pool Alarm
  None             Other:                                          Turtle Alarm on child           Other:
Personal Floatation Device (PFD) Unknown
  Yes      No                                                    Access to Pool by Victim:         Unknown
Appropriate PFD Type/Size Unknown                                  Direct Access/No Barriers
  Yes      No, why_________________________________                Brought in to water area by other person
                                                                   Victim breached safety barrier(s): (choose all that apply)
             WATER SOURCE INFORMATION                                 Fence      Pool Cover        House Window
Site of Incident:           Unknown                                   Gate       Pool Alarm        House Door
   Victim Residence         Relative Residence                        Other:
   Neighbor Residence       Friend Residence
                                                                 Explain how victim got through barrier(s):
   Sitters/Daycare Provider Public Pool
   County/City Park         Other:

Water Clarity:               Water Depth:
                                                                        C: CLASSES/EMERGENCY PREPARATION
 Clear      Cloudy            Under 18”(approx. depth ____)
                                                                 Was rescue equipment near water? (Shepherd’s hook, life
 Muddy Green                  18” – 48”    Over 4’
                                                                 ring, etc…)   Yes   No     Unknown
 Unknown                      Unknown
                                                                 Did bystanders attempt CPR?
Water Type:                       Unknown
                                                                   Yes No       Unknown
 Pool – in ground                 Spa/Hot Tub    Bathtub
 Pool – above ground              Toilet         Bucket          Did victim ever take swim lessons or water safety classes?
 Child wading pool                Lake or pond   Stream/river      Yes No        Unknown
 Canal/irrigation ditch           Other:
                                                                 Did supervisors ever take CPR?
Toys or other objects in water?          Unknown                   Yes No        Unknown
  No     Yes    If yes, describe:

Year pool/spa was built:                 Unknown    N/A          VICTIM CONDITION:
                                                                   Treated/released at scene
How long has current resident lived at this address?               Transported to hospital ___________________________
                                     Unknown N/A                   Deceased at scene

Form Completed by:                                               COMMENTS:
                           FAX Completed Form to: (909) 358-7175, Injury Prevention Services,
Contact Phone:                  ATTN: Kristin Goffman. Questions? Call (909) 358-7171