3rd September 2010  
Scubasure insurance for Sports Divers
         
 
 

Incident Input Form
Please enter as much information as possible
Details of Incident  
Date
/ /
Time
:
Federation
 
Location
Organisation of Dive
Location Type
Country

Dive Details
Maximum Depth of Dive
M
Depth at which incident started
M
Dive Duration
hrs : min
Weather
Surface Viability
M
Decompression conducted: Depth(s)
M
M
M
M
: : : :
Time(s)
Surface Interval Since Previous Dive
:
Sea/Water Surface Conditions
Underwater Visibility
M

Details of Previous Related Dives  
Previous Dive 1
 
Maximum Depth of Dive
Metres
Dive Duration
:
Decompression conducted: Depth(s)
M
M
M
M
: : : :
Time(s)
Surface Interval Since Previous Dive
:
Previous Dive 2
 
Maximum Depth of Dive
Metres
Dive Duration
:
Decompression conducted: Depth(s)
M
M
M
M
: : : :
Time(s)
Surface Interval Since Previous Dive
:
 
Type of Incident and Factors involved
(please select all that apply)
Section 1
 
Fatality
Ear Problems / Damage
Embolism
Hypothermia
Decompression Illness
Breathlessness
Unconsciousness
Panic
Injury
Cramp
Illness
Resuscitation Involved
Narcosis
First Aid Oxygen Used
Oxygen Poisoning
   
Section 2
 
Nitrox
Trimix
Rebreather
   
Section 3
 
Aborted Dive
Diver Too Buoyant
Ascent Using Alternate Air Source
Diver Too Heavy in Water
Buoyant Ascent
Out of Air
Free Ascent (w/o air supply)
Foul Air
Controlled Buoyant Lift
Incorrect Gas Mixture
Rapid Ascent
   
Section 4
 
Rough Water
Low Underwater Visibility
Cold Water
Low Surface Visibility
Water Current
   
Section 5
 
Good Practice
Malice
Bad Seamanship
Inadequate pre-dive check
Good Seamanship
Inadequate Training
Carelessness
Entangled/Trapped
Ignorance
Fire/Explosion
Disregard of Rules
False Alarm
Section 6
 
Solo Diving
Training Drill
Trio Diving
Diving at Altitude(250m +)
Separation
Divers Underwater
Lost Diver(s)
Divers on Surface
Drift Diving
   
Section 7
 
Wreck Dive
Snorkel Dive
Cave Dive
Boat Dive
Night Dive
Shore dive
Emergency Services
 
Coastguard
Hospital
Lifeboat
Police
Helicopter
Fire Brigade
Ambulance
Recompression
Decompression Incidents
 
Dive within tables
Inaccurate use of tables
Other Tables
please specify
 
 
Dive using computer
Computer details
Computer make
Computer model
Computer serial number
Computer age
Dive within computer limits
Re-entry decompression
Missed decompression stops
Repeat diving

Details of Individual Involved
Person 1
 
Surname
First Name
Gender
Age
years
Previous Medical Condition
Training Agency
Branch name
Branch number
Membership Number
Diving Grade
Instructor Grade
Dives This Year
Total Dives
Year Started Diving
Gas Mixture Used
 
Dive
Stops
Air  
Nitrox 32
Nitrox 36
Nitrox 50
Other Please Specify
Person 2
 
Surname
First Name
Gender
Age
years
Previous Medical Condition
Training Agency
Branch name
Branch number
Membership Number
Diving Grade
Instructor Grade
Dives This Year
Total Dives
Year Started Diving
Gas Mixture Used
 
Dive
Stops
Air  
Nitrox 32
Nitrox 36
Nitrox 50
Other Please Specify
Person 3
 
Surname
First Name
Gender
Age
years
Previous Medical Condition
Training Agency
Branch name
Branch number
Membership Number
Diving Grade
Instructor Grade
Dives This Year
Total Dives
Year Started Diving
Gas Mixture Used
 
Dive
Stops
Air  
Nitrox 32
Nitrox 36
Nitrox 50
Other Please Specify
Person 4
 
Surname
First Name
Gender
Age
years
Previous Medical Condition
Training Agency
Branch name
Branch number
Membership Number
Diving Grade
Instructor Grade
Dives This Year
Total Dives
Year Started Diving
Gas Mixture Used
 
Dive
Stops
Air  
Nitrox 32
Nitrox 36
Nitrox 50
Other Please Specify

Equipment Details that contributed to the incident (Only tick those that contributed to the accident)
Diving Equipment
 
Cylinder
Face mask
Regulator
Full face mask
Pressure Gauge
Snorkel
Hose
Knife
BC
Watch
ABLJ
Compass
Drysuit
Dive computer
Undersuit
SMB
Wetsuit
Delayed SMB
Dump Valve
SMB Reel
Inflation Valve
Lifting bag
Hood
Rope
Gloves
Torch
Weight/Weightbelt
Camera
Ankle weights
Tools
Other - please specify
Boat and boating equipment
     
Engine failure/malfunction
Boat swamping
Out of fuel
Boat capsize
Incorrect or dirty fuel
VHF radio failure
Boat malfunction
Propellor
Other - please specify

Faulty item details
Item
Make
Model
Serial No
Approximate Age
years

Summary
Description of Incident

Incident Submitted By  
Reported By
Address
Date
 
 
 
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