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Accident report form

ALL REPORT OF OCCURRENCE FORMS ARE NOW SUBMITTED DIRECTLY ONLINE AT THIS EASY TO USE LINK:  http://www.usaswimming.org/ROO.
 
Insurance and Risk Management Information can be found on the USA Swimming website at:  http://www.usaswimming.org/insurance.  

Please, if you are a swimmer or parent report accident immediately to your coach and the Accident report will beimmediately filed by that coach and submitted tothe links above.

It is important that any accident or incident occurrence gets reported immediately to USA Swimming, .  Injured patrons or athletes are expected to report immediately, as are employees who observe an incident.  The form for swim team incidents is directly below:

 Reporting all incidents, no matter how minor, is important to put both USA Swimming, MCAT and its 
insurer on notice of accidents and potential claims.
A Report of Occurrence form should be submitted any time an injury occurs at a USA 
Swimming function, whether or not it involves a USA Swimming member. To 
summarize, injuries involving spectators should also be reported.  The form should be 
filled out by a meet director or by any club personnel responsible at the time of the 
incident; the parents of the injured athlete should not be asked to complete the report 
form.
After receiving the report, USA Swimming National Headquarters enters information 
about the incident into the USA Swimming database for future safety education and 
insurance references.  When a Report of Occurrence form indicating an athlete or non athlete participant is a USA Swimming registered athlete, information about the Excess 
Accident Medical Insurance Policy and claim forms are sent to the injured party(’s) 
family.  This program is excess to other primary insurance in place through the 
member's employment, school or family.  The deductible is the greater of the total of 
other collectible benefits from primary insurance sources applicable to the injury or 
$100 when there is no primary insurance.  
 
The Report of Occurrence forms inform Risk Management Services, Inc. of potential 
claims or liability situations.  If the accident is of a serious nature, USA Swimming 
National Headquarters confers with Risk Management Services and an investigation of 
the incident is initiated.Revised 05/2012
For use only if submitting online is not available:    USA SWIMMING
            Report of Occurrence
(Circle one)  Personal Injury/Property Damage/Other                                                                            
(Please Print Clearly)
Date of Incident:  _____________ Time of Incident: ___________ LSC:  _____ Name of Club:                                                            
Injured:   Athlete  Coach  Official  Member/other: _________________  Guest/Spectator  Other:     
         
Name (Legal):                                                                                          USA Swimming ID#: ______________________________     
                                                
Address:                                                                                     City/State/Zip: ___________________________________________    
        
Date of Birth:                                Age:            Sex:   M  F      Phone:  (____) _____________________________________                
                                                                                                                                                                                
Where did the incident occur?:    In Water     Deck      On Blocks      Locker Room     Bleachers     Hallway     Stairs        
                                                      Gym     Outside Venue (List) ______________________   Other _______________________ 
Activity:       Meet/Competition    Meet/Warm-up       Meet/Warm down             
      Practice/Water  Practice/Dry-land  Other: ______________________________________
Facility Name:                                                                                      City/State: _______________________________________   
Facility Type:   Indoor  Outdoor                                                              
Describe the incident:     
                                                                                                                                                                         
    
                                                                                                                                                                                                                
                                                                                                                                                                                                                  
                                                                                                                                                                                                            
Affected Body Part (Specify R or L):    Head/Neck    Leg/Foot    Ears/Nose/Mouth/Teeth    Hand/Arm    Knees 
  Shoulder    Torso    Internal    Other: ______________________________________    
                                                                       
Describe the Injury: ___________________________________________________________________________________________    
                                                                                                                                                                     
On Site Care Given by:   Coach  Parent  EMT/Paramedic  Facility Staff: _________________   
name of person giving care
Care Given on Site:   Ice  Immobilized  Bandage  Cleaned  Other:  ______________________    
Care Refused by Injured:   Yes  No
If yes, Signature of Injured or of Guardian/Parents if under 18 yrs of age: ________________________________________________
Parent/Guardian notified:  No   Yes   Comment? ________________________________________________________________
Taken to Clinic/Hospital:  No    Yes    If yes, location: ____________________________________________________________
                                                                                                                                                                                                            
Please include names and phone numbers of two (2) witnesses: (If others, list on reverse)
                                                                                                                                                  (____)______________________________  
Name Address                     Phone
                                                                                                                             (____)______________________________  
Name Address   Phone
Activity Supervisor:    _________________________________ (___) ___________________    (____) __________________________
                                                      Please print                                                                            Daytime Phone                                Evening Phone
Report Submitted By: _________________________________ (___) ___________________    (____) __________________________
                                                      Please print                                                                            Daytime Phone                                Evening Phone
Date Report was submitted: ____________________________
Club Personnel/Club Safety Coordinator is responsible for returning completed form immediately following incident to:           
USA Swimming and: Risk Management Services, Inc.           and:   LSC Safety Chairman
Risk Management Department P. O. Box 32712
1 Olympic Plaza Phoenix, AZ  85064-2712
Colorado Springs, CO  80909 FAX:  (602) 274-9138
FAX:  (719) 866-4050s [email protected]
[email protected]                   Please attach any additional reports (facility reports, newspaper articles, witness statements).