971) 673-0451 FAX (971) 673-0457 This report must be completed for every physiciantreated accident or any drowning at a public swimming pool. It is the responsibility of the pool operator to submit the completed form promptly to the Oregon Health Authority, Public Pool Program, 800 NE Oregon, Portland, OR 97232-2162 Date of Incident Time: YY MM - DD Accession # Accident ID # Official Use Only Victim Information - Please do not identify the victim by name. If there are multiple victi.
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How to use or fill out the OR PHD 100 online
Filling out the OR PHD 100 form, which is the public swimming pool accident and drowning report, is essential for documenting incidents at public pools. This guide offers comprehensive instructions to help users complete the form accurately and efficiently.
Follow the steps to successfully fill out the OR PHD 100 form.
- Press the ‘Get Form’ button to access the OR PHD 100 form and open it in your chosen digital editor.
- Begin by entering the date and time of the incident in the designated fields at the top of the form.
- Fill in the unique identifier for the victim in the victim information section, avoiding the use of their name.
- Input the victim's residence city or town, zip code, and make sure to specify whether the incident was fatal or non-fatal.
- Indicate the age of the victim and check any possible contributing medical conditions that apply.
- Select the type of injury from the provided options, and specify any additional information regarding the area of the body injured.
- Mark whether treatment was required and specify the nature of treatment.
- Provide information about the pool, including the name, address, contact person, and whether the pool was open at the time of the incident.
- Detail the circumstances surrounding the incident, such as supervision of minors, presence of a lifeguard, and staff involvement.
- Identify any contributing factors to the incident by marking the applicable options and provide a description of what happened.
- Complete the section regarding additional injuries and ensure all descriptions are clear and legible.
- Conclude the form by printing or typing your name, providing your signature, and adding the date before submitting it.
Ensure the safety of your facility by completing the OR PHD 100 form accurately and submitting it online.
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