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Summer Swim Team
GMSS – Incident Report
GMSS - Report of Occurrence
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Form filled out Date and time
Injured Party Information
First Name
Last Name
Address
City
State
Zip Code
Phone (include area code)
Email
Gender
Please Select
Female
Male
Date of Birth (mm/dd/yyyy)
Is the injured party an employee?
Please Select
Yes
No
Section Break
Employee Information
Employee's Job Title When Injured
Date GMSS Notified of Injury
What was the employee doing just before the accident occurred?
Is the validity of the Injury in doubt? If so, please explain.
Section Break
Accident Information
Date of Accident (mm/dd/yyyy)
Time of Accident
:
Hours
Minutes
AM
PM
AM/PM
Where Injury Occurred
School - Lobby
School - Changing Area
School - Pool
School - Parking Lot
School - Employee Only Areas
Other - Offsite Competition location
Other - Offsite Practice location
Other
Other - Please describe where the injury occured
Activity When Accident Occured
Swimming
Waiting/Spectating
Walking/Running
Work related - Employees only
Other
Other and Work related activities
Please describe activity when the injury occurred
Source of Injury
Slip/ Trip/ Fall
Struck Against/ Ran Into
Lifting/ Straining
Insect Sting/ Bite
Foreign Body
Air Quality
Heat/ Sun
Other
Other - Please describe source of injury
Additional Details of Accident
Facility Information
Facility Name
Injury Information
Body Part Injured
Head
Face - Eye
Face - Ear
Face - Nose
Face - Mouth/Teeth/Lips
Face - Chin
Neck
Back
Chest/Stomach
Arm/Wrist
Hand/Finger
Leg
Knee
Ankle
Foot/Toe
Other or Multiple body parts involved
Please describe injured body parts
Symptom
Cut
Bruise
Sprain
Concussion
Unconsciousness
Fracture
Dislocation
Swelling
Scrape
Shortness of Breath
Vomiting
Burn
Seizure
Other
Other - Please describe symptom
Additional Details of Injury
Upload all relevant documents and photos
Max. file size: 20 MB.
First Aid Information
On Site Care Given
Please Select
Yes
No
Care Refused by Injured
Please Select
Yes
No
Taken To Hospital
Please Select
Yes
No
Parent/ Guardian Notified
Please Select
Yes
No
Parent/Guardian Phone
Has a follow up with the student/client and parent/guardian been made?
Please Select
Yes
No
Date of follow up
Contact Information For Two Witnesses
Name (witness one)
Phone (including area code)
Email
Name (witness two)
Phone (including area code)
Email
Supervisor on Duty's Name
Contact Phone
Report Submitted By
First Name
*
Last Name
*
Contact Phone
Contact Email
Click the SUBMIT button when you have completed the form. You will receive an email copy of your submission. If additional information is needed a Gold Medal Swim School manager will contact you. Thank you for your assistance.
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