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Get Template Incident Report Form Swimming Pool

Ambulence, or Emergency Room Visit Required (circle one) : Name of Victim : YES Age : Witnesses Name : Age : Name : Age : Description of Incident and Action Taken: Police Report Attached (circle one) : Owner Signature: DHEC 3785 (07/01) d) Other YES NO Date: NO Sex : D E F Purpose: This form is to be used by public pool owners or operators in the event of a patron death, injury, or accident requiring an EMS response, an emergency room visit, or hospitalization. This application.

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