10. DIVING ACCIDENT REPORTING WORKSHEET

THIS FORM IS DESIGNED TO BE FILLED OUT IN THE FIELD AND ACCOMPANY THE DIVER TO HOSPITAL

NAME AND ADDRESS OF DIVER:


DETAILS OF DIVE:  DEPTH ______  BOTTOM TIME ______ DECOMPRESSION TIME _________


EVENTS PRECEDING THE ACCIDENT, e.g. RAPID ASCENT, ILLNESS, ETC.



ACCIDENT DESCRIPTION:



DIVING HISTORY (including depths, times, and surface intervals for the last 48 hours)




PLEASE RECORD ANY SYMPTOMS AND SIGNS AND THE CORRESPONDING ON SET TIMES.

SYMPTOMS AND SIGNS:				TIME FIRST OBSERVED:
	FATIGUE
	RASH OR ITCHING
	JOINT PAIN
	PARALYSIS OR WEAKNESS
	NUMBNESS OR TINGLING
	DIZZINESS OR DISORIENTATION
	NAUSEA
	DECREASED CONSCIOUSNESS
	BREATHING DIFFICULTY
	VISION OR SPEECH DIFFICULTY
	CHEST PAIN
	PERSONALITY CHANGE
	BLOODY FROTH FROM NOSE OR MOUTH
	CONVULSIONS
	UNCONSCIOUSNESS
	STOPPED BREATHING
	NO PULSE

OTHER:


FIRST AID GIVEN:				TIME GIVEN:						





PERSON COMPLETING FORM: __________________  _____________________ DATE ________________
			NAME			SIGNATURE

DAN EMERGENCY: (919) 684-8111

DSM96