Free Swimming Pool and Water Attraction Death, Injury and Illness Report, DPH 45036 - Wisconsin

85DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 45036 (2/08)

STATE OF WISCONSIN Bureau of Environmental and Occupational Health HFS 172, Wisconsin Administrative Code

SWIMMING POOL AND WATER ATTRACTION DEATH, INJURY AND ILLNESS REPORT
HFS 172.32 (2) The operator shall report incidents resulting in death, or serious injury or illness that requires assistance from emergency medical personnel, by the end of the next working day following the incident by telephone or fax to the department or agent. Personally identifiable information on this form is collected to provide for the potential of further investigation. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m)]. Please use one form for each injured party. The operator shall maintain a copy of this report for at least seven years. Report only those injuries or illnesses that require assistance from emergency medical personnel. Mail or Fax report to: Division of Public Health, Bureau of Environmental and Occupational Health, P. O. Box 2659, Madison, WI 53701-2659 Telephone No. 608-266-2835, Fax No. 608-267-4853 Please Print All Information Establishment Name Establishment Street Address, City, State and Zip Code Legal Licensee Contact Person Type of Pool or Water Attraction Telephone No. Facility ID No.

Name of injured party Address, City, State and Zip Code Was injured party: Employee Patron Other

Date of Birth

Age

Gender

Telephone No. Telephone No. of Contact Person

Contact Person for injured party Type of Incident: Death Injury Illness

Date and Time of Incident

Description of Incident (Use back side of form for additional pages, if needed)

List Name(s) of Lifeguard(s) on Duty

Name of person completing form (Please print )

Position/Title

SIGNATURE ­ Person Completing Form

Date Signed