GMSC – Report of Occurrence

GMSC - 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
Date of Birth (mm/dd/yyyy)
Age at Time of Accident
USA Swimming Member
USA Swimming ID (if known)
Accident Information
Date of Accident (mm/dd/yyyy)
Activity at Time of Injury
- Meet - Competition
- Meet - Warm-up
- Meet - Warm Down
- Meet - Entering/Exiting Pool
- Meet - Watching/Observing
- Meet - Walking
- Practice - Entering/ Exiting Pool
- Practice - Swimming
- Practice - Dry Land
- Practice - Other
- Other
Other - Please describe activity at time of injury
Where Accident Occurred
- Water - Start End
- Water - Turn End
- Water - Side of Pool
- Water - Bottom of Pool
- Water - Lane Lines
- Bleachers
- Deck
- Starting Blocks
- Locker Room
- Team Area
- Hallway/Stairs
- Gym
- Outside Venue
- Other
Other - Please describe where 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
Swim Club Responsible for the Pool
Address
City
State
Zip Code
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: 500 MB.
First Aid Information
On Site Care Given
Care Refused by Injured
Taken To Hospital
Parent/ Guardian Notified
Parent/Guardian Phone
Has a follow up with the athlete and parent/guardian been made?
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
Activity/ Meet Supervisor 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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