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).