Fillable Swimming Pool Injury/Drowning Report Form (Hennepin County)

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Swimming Pool Injury/Drowning Report Form (Hennepin County)

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Page 1 of 2
Swimming Pool Injury/Drowning Report Form
(INCLUDES SWIMMING POOLS, WADING POOLS, THERAPEUTIC POOLS,
PLUNGE POOLS AND SPA POOLS)
Minnesota Department of Health
Swimming Pool Engineering
P.O. Box 64975
St. Paul, Minnesota 55164-0975
651-201-4503
www.health.state.mn.us/divs/eh/pools
In accordance with
Minnesota Rule, 4717.0775
, all pool incidents resulting in death or serious injury that
require assistance from emergency medical personnel must be reported to the commissioner by the owner or
the owner’s agent by the end of the next working day.
Facility Information
Facility Name:
Facility Address:
City: State: ZIP:
County: Facility Phone:
Licensee Name:
Form Completed By
Name:
Address:
City: State: ZIP:
Contact Phone:
Injured Person/Drowning Victim
Name:
Address:
City: State: ZIP: Phone:
If victim under 14 years, was adult present? Yes No
Gender: Male Female Age: Swimmer Non-swimmer Unknown
Incident
Date and time of incident:
Type of Pool:
Swimming Pool
Wading Pool
Therapeutic Pool
Plunge Pool Spa Pool Other ________________________
Year pool was constructed: Water depth of incident: Indoor pool outdoor pool
Was a lifeguard present: Yes No
Page 2 of 2
Specific Information
Pool Injury Successful Rescue Drowning Other _________________________________________________
How and where did incident occur?
(Specify)
Area of the body injured:
(Check all that apply)
Head Torso
Arm/Hand/Finger Leg/Foot/Toe
Neck/Spine
Other (Specify) _________________________________
________________________________________________
Type of injury:
(Check all that apply)
Abrasion or Contusion Strain or Sprain
Concussion Fracture
Laceration Sudden Illness
Other (Specify) ________________________________
________________________________________________
Factors Contributing To The Incident
(check all that apply)
Slippery surfaces: Around pool Bottom of pool Other ________________________________________________
Deck equipment: Ladder/handrails Lifeguard equipment Other _______________________________________
Recirculation equipment: Suction Electrical Other __________________________________________________
Use of pool equipment: Storage Handling Other __________________________________________________
Pool enclosure: Inadequate Gate – unlatched or unlocked Other ______________________________________
Diving/jumping/sliding: From board From poolside From slide Other _______________________________
Horseplay/Miscalculation:
(Specify)
Other:
(Specify)
Involved food/drink Natural causes
Were others injured: Yes No
(If yes, list name(s))
Email completed form to Steve Klemm at steve.klemm@state.mn.us
or mail to the Minnesota Department of Health,
Swimming Pool Engineering, P.O. Box 64975, St. Paul, Minnesota 55164-0975.
Form revised 6/24/2015
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Swimming Pool InjuryDrowning Report Form (Hennepin County)

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Completed 24 December 2020

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