007.04.3 Appendix H. Report of Accident or Drowning at Pools, Spas or Other Related Facilities
AR ADC 007.04.3 Appendix HArkansas Administrative Code
Ark. Admin. Code 007.04.3 Appendix H
007.04.3 Appendix H. Report of Accident or Drowning at Pools, Spas or Other Related Facilities
ARKANSAS DEPARTMENT OF HEALTH
ENVIRONMENTAL HEALTH PROTECTION
ENVIRONMENTAL HEALTH SERVICES
REPORT OF ACCIDENT OR DROWNING AT POOLS, SPAS OR OTHER RELATED FACILITIES
GENERAL INFORMATION
Name of Facility: _______________ Address: _______________ City: __________
Name of Victim: _______________ Address: _______________ City: __________
Date of Incident: _______________ Time: _____ am/pm Accident 
Drowning Fatality
Drowning Fatality Description of water and weather conditions at time of the incident: ____________________
Name of employees involved in rescue attempt or treatment of injury:
Facility open at time of incident Yes No Lifeguard on duty Yes No Bather load: __________
No Lifeguard on duty Yes No Bather load: __________VICTIM: Male Female Age: __________ Non-Swimmer Yes No
Female Age: __________ Non-Swimmer Yes No FACILITY: Indoor Outdoor Spa Pool Water Slide Other (Specify): _______________
Outdoor Spa Pool Water Slide Other (Specify): _______________Emergency telephone provided: Yes No
Type of lifesaving/first aid training of employees involved: _________________________
TYPE OF INJURY: Abrasion or contusion Concussion Fracture Laceration Strain or Sprain
Concussion Fracture Laceration Strain or Sprain Other (Specify): ____________________
(Specify): ____________________AREA OF BODY INJURED: Head Trunk Arm, hand or finger Leg, foot or toe
Trunk Arm, hand or finger Leg, foot or toe Other (Specify): _____________________________________________
(Specify): _____________________________________________DESCRIPTION OF INJURY: ___________________________________________
FACTORS WHICH MAY HAVE CONTRIBUTED TO ACCIDENT
Slippery Surface: Surrounding pool Bottom of pool Steps
Bottom of pool Steps Other (Specify): _____________________________________________
(Specify): _____________________________________________Deck Equipment: Ladders or handrails Lifeguard equipment
Lifeguard equipment Other (Specify): _____________________________________________
(Specify): _____________________________________________Pool Enclosure: Inadequate Gate unlatched Horseplay involved
Gate unlatched Horseplay involved Other (Specify): _____________________________________________
(Specify): _____________________________________________Recirculation/Filtration Equip.: Mechanical Electrical Missing/broken equipment
Electrical Missing/broken equipment Other (Specify):
(Specify):Diving, Jumping or Sliding: From board From poolside From slide
From poolside From slide Other (Specify): _____________________________________________
(Specify): _____________________________________________Other: Swimming miscalculation Natural causes Use of alcohol
Natural causes Use of alcohol Chemical or chemical related accident: Yes No
No If Yes, chemicals involved: _____________________________________________
Brief description of accident: ___________________________________________
Were police, rescue unit or other emergency personnel called: Yes No
No If Yes, list: _____________________________________________
Brief description of emergency action taken on site: ___________________________________
Degree of treatment required: None CPR First aid Emergency room Hospital admission
CPR First aid Emergency room Hospital admission If necessary, make a sketch of the pool/spa area involved in the injury or accident
Additional remarks relevant to this accident: ___________________________________
____________________ | ____________________ | _______________ | |
Signature | Title | Date | |
Credits
Adopted Aug. 1, 2012.
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 007.04.3 Appendix H, AR ADC 007.04.3 Appendix H
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