Instructions for completing the Water Incident Report Form

The following guidelines will help you fill out the WIRA Water Incident Report Form.

These instructions are also available in a printable two-page Word *.doc format that can be photocopied for easy reference by front-line staff who are responsible for completing the form. The form is also available in Acrobat PDF format.

Top of Page:  Fill in “Your File Number” if your agency has a file number which can be used for follow-up phone calls. Fill in your name as the “Reporter” who is filling out the form, and the name of your organization as the “Agency” (if it is not already filled in) and include a telephone number for contact.

Please fill in the date and time of the incident and indicate the “light conditions”. Check “dark” if conditions at the scene of the incident were dark.  Check “light” if during the day, twilight or indoors with artificial light. Complete the name of the city or town, the province, and the county or regional municipality where the incident occurred. Many incidents do not occur within the boundaries of a city or town, therefore use the city or town nearest the incident and include the postal code. Fill in the name of the body of water or facility in which the incident occurred.

Please fill in the age of the victim at the time of the incident and check the appropriate box for gender. Indicate the swimming ability of the victim before the incident occurred.  “Swimmer” includes weak and strong swimmers.  If the victim was alone when the incident occurred, check “yes” i.e. there was no one else in the line of sight of the victim when the incident occurred. Fill in the name of the city or town and the province or territory that the victim was living in at the time of the incident.

Type of Incident: Check the single most relevant cause of the incident. Check “major injury” only if the victim was admitted to hospital as an in-patient.  Check “minor injury” for all other injuries that required medical treatment beyond first aid by front-line staff or bystanders, including emergency room or out-patient hospital treatment, doctor or dentist follow-up or activation of EMS, ambulance, fire or police services follow-up.  If the victim died, check fatality only.  If no medical follow-up beyond first aid was required, but a lifeguard had to enter the water to rescue the victim, check “rescue only”.  If a rescue was performed, and the victim was also injured, check only the appropriate injury or fatality, not “rescue only”. Check “presumed drowned” if the victim has gone missing and it has not been confirmed that he/she is deceased.

Cause of fatality or factors contributing to non-fatal incident: Check all that apply. There may be several factors within an incident. Please be sure that the box is only checked if it was a factor contributing to the incident.

Drowning: Check this box if the victim’s cause of death or reason for rescue is the act of drowning.

Medical Factor, (please specify, i.e., Epilepsy, Seizure, Cardiac Problems): Check this box if the victim experiences a seizure, cardiac problem or other medical factor which led to the incident.

Non-Swimmer: Check this box if the victim is injured or drowned or rescued as a direct result of the victim’s inability to swim.

Not Wearing a PFD: Indicate if not wearing a PFD or lifejacket was a factor that led to the incident.

Drugs: Check this box if drug use is a direct factor in the death or rescue of the victim. This includes illegal drugs as well as legal prescription drugs.

Hypothermia: Check this box if direct exposure to cold/hypothermia is the cause of death or injury.

Trauma: Check this box if the victim dies of, or is hospitalized as a result of extensive injuries (blunt/penetrating) sustained in the incident. Also includes barotraumas from compressed air/gas diving.

Weather: Check this box if the weather played a direct part in the incident. For example: a sudden storm which causes the water to become rough enough to capsize a vessel.

Personal Factors: This category applies to the personal circumstances and activities that lead to the injury. These activities vary and include such actions as walking, running, jumping, colliding, diving, falling, sliding, slipping, tripping, and other physical actions in “contact” and “non-contact” activities. Fatigue and heat exhaustion from overexertion, bumps, bruises, burns, abrasions, cuts, contusions, concussions, dislocations, bone fractures, muscle sprain and strain, can potentially result when a victim voluntarily exposes themselves to risk situations and fails to exercise due care which contributes to the injury.

Equipment Factors: This category applies to the failure of equipment to react as expected contributing to the victim’s injury. Types of equipment include PFD’s and other safety equipment including floatation devices and non-safety equipment such as the supplies, accessories and other tackle used for the specific activity. This category refers to all incidents whereby the equipment in use is at fault and directly led to the injury. In cases where the wrong type of equipment was employed or the equipment was not worn or used properly, or maintained, the victim is at fault and the previous category applies.

Environmental Factors: Check this box when the causes or circumstances contributing to the injury are due to the environment or the physical surroundings. This category includes the characteristics and conditions of the site (type, nature, and inclusions), safe minimum diving depth, slope of the pool floor, length etc. and other design specifications, and the conditions of the site including but not restricted to the following: slippery surfaces, obstructions, hazardous objects etc. This category also includes earth surface movements such as the collapse of a dam or other man-made structure/excavation, cliff or other natural embankment/elevation and other natural forces such as rapids and waterfalls.

Other: When none of the listed categories apply check other and then specify the cause of the incident.

Alcohol Involved: Check “yes” if there is a strong indication that alcohol was consumed before the incident.  For example, the victim was seen drinking or the police tested for or state they suspect alcohol consumption.

Type of Location: Check one box only to further specify the location of the incident. When none of the listed categories apply, check “other” and specify the location of the incident.

Purpose of victim’s activity: Check “attempted rescue” if the victim was injured or had to be rescued themselves while attempting to rescue another person. Check “recreational” if the victim was in, on or around the water or ice for the purpose of leisure or recreation.  Check “occupational” if the victim was in, on or around the water for the purposes of their work/employment.  Check “daily living” if the victim was in, on or around the water or ice as part of their daily living activities (eg. travel, bathing, walking to the store).

If recreational, specify activity of victim:

• Walking/running near water or on ice: Check this box if the victim is intending to be engaged in an activity near water or ice when the incident occurred. Includes running on pool deck, etc.
• Playing near water or on ice: Check this box if the activity in which the victim is engaged, is intended to be part of the recreational activity. An example could include beach volleyball where the victim chases the ball into the water and an incident occurs while in the water. Also includes ice skating for on-ice incidents.
• Playing in water/wading/water sliding: Check this box if the victim is engaged in these particular activities.
• Swimming: Check this box if the victim is a swimmer and the incident occurs while the victim is swimming.
• Camp/Lesson: Check this box if the incident occurred while at camp or during an instructional lesson.
• Diving/Jumping: Check this box when the incident occurs as a result of diving or jumping (from shore/deck/dock/cliff, etc. into the water).
• Fishing: Check this box if the victim is engaged in fishing as the recreational activity from a boat or land.
• Hunting: Check this box if the victim was engaged in the activity of hunting for sport.
• Scuba Diving: Check this box if the victim was skin diving with scuba apparatus or other scuba gear.
• Other: If the type of activity is not among the indicated list of choices, please specify the activity.

Type of activity victim involved in: Check ”in-water aquatic” if the victim was in the water and intended to be there when the incident occurred (includes bathing incidents).  Check “non-aquatic” and proceed to the synopsis if the victim did not intend to be in the water at the time of the incident, but was near or on the water or ice. Includes on-ice incidents and near-water incidents such as falling into the water from the shore, dock or deck.

Did incident occur in an aquatic facility or public waterfront: Check “yes” and specify the agency name if the incident occurred at a public waterfront or in an aquatic facility open to the public with organized access to the water, whether lifeguard supervision was on duty or not at the time of the incident.  Includes public pools; hotel, apartment pools, private clubs and camps; organized beaches/waterfronts in national, provincial and municipal parks and conservation areas.

Weather/water: Check “rough water” if white caps or storm/gale force wave conditions were present at the time of the incident.  Check “cold water” if the water temperature was known or estimated to be 15 degrees Celsius or lower (less than 60 degrees Fahrenheit). Check “calm” if water conditions are undisturbed or controlled as in pool water at aquatic facilities. For “other”, specify any known relevant information contributing to the incident re: currents, wind, fog, rain, snow/ice etc.

Please indicate whether there was a qualified lifeguard on duty at the time of the incident. If safety equipment was used in the rescue, specify the type of equipment that was used. If a rescue was attempted, check off the appropriate box(s) and indicate whether or not the rescuer entered the water in order to rescue the victim. If a rescue was attempted, indicate whether or not the rescuer was successful in rescuing the victim. If not, please specify why.

Synopsis: This space is left for the reporter to summarize in further detail what happened in the incident.  This field is very important as it helps us ensure that the all boxes have been filled in properly.

If you have any other questions about how to complete the form, please contact the

Water Incident Research Alliance at (705) 735-0544 or email: info@waterincident.ca.

Forward the completed Water Incident Report Form by fax (preferred) or mail: