Swimming Pool Injury/Drowning Report Form
INCLUDES SWIMMING POOLS, WADING POOLS, THERAPEUTIC POOLS,
PLUNGE POOLS AND SPA 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 ☐Plunge Pool ☐Wading Pool ☐Spa Pool ☐Therapeutic Pool
☐Other _____________________________
Year pool was constructed ______ Water depth of incident _______ ☐Indoor pool ☐outdoor pool
Was a lifeguard present? ☐Yes ☐No
SWIMMING POOL INJURY/DROWNING REPORT FORM
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 ☐Arm/Hand/Finger ☐Neck/Spine ☐Torso ☐Leg/Foot/Toe ☐Other ___________________
Type of injury (Check all that apply)
☐Abrasion or Contusion ☐Concussion ☐Laceration ☐Strain or Sprain ☐Fracture ☐Sudden Illness
☐Other ____________________
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 ☐Involved food/drink ☐Natural causes
Please specify:
Were others injured? ☐Yes ☐No
If yes, list name(s):
Mail or email completed form to
Minnesota Department of Health
Swimming Pool Engineering
P.O. Box 64975
St. Paul, Minnesota 55164-0975
09/22/2023 | To obtain this information in a different format, call: 651-201-4500.
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