SUBMERSION INCIDENT REPORT FORM (SIRF) CORONA POLICE DEPARTMENT 730 PUBLIC SAFETY WAY CORONA, CALIFORNIA 92880-2002 CA0331500 BASIC INCIDENT INFORMATIONDate of Incident MM slash DD slash YYYY Time of Incident Your Agency's Incident Number Reporting Agency Street Name Incident City Zip Code Type of Dwelling: House Apartment Condo Hotel/Motel N/A Other Type of Dwelling: OtherDescribe VICTIM INFORMATIONAge of Victim Sex M F Victim’s Race/Ethnicity: Unknown American Indian Asian PI Black Hispanic White Multi racial Other Victim’s Race/Ethnicity: OtherDescribe Victim Last Seen: Unknown Swimming Playing Outside Playing Inside Sleeping Other Victim Last Seen: OtherDescribe Est. Length of Time Submersed Est. Length of Time Submersed Unknown Type of Clothing Worn by Victim: Unknown Swim suit Day clothing Pajamas None Alcohol and/or drug use evident? Yes No Unknown WATER SOURCE INFORMATIONSite of Incident: Unknown Victim Residence Relative Residence Neighbor Residence Friend Residence Sitters/Daycare Provider Hotel/Motel Public (community, county, city) Other Site of Incident: OtherDescribe Water Clarity: Clear Coudy Muddy Green Unknown Water Depth: Under 18″ 18″ – 48″ Over 4′ Unknown Water Type: Unknown Pool – in ground Pool – above ground Child wading pool Canal/irrigation ditch Spa/Hot Tub Toilet Lake or pond Bathtub Bucket Stream/river Other Water Type: OtherDescribe Toys or objects in water? Yes No NA Unknown Describe: A: ADULT SUPERVISIONSupervisor(s) at time of incident: Unknown NA = Adult Mother Father Sibling Grandparent Babysitter/Childcare Provider Pool party in progress at time of submersion Other Supervisor at time of event: OtherPlease Specify Supervisor activity immediately prior to incident: Supervisor activity immediately prior to incident unknown Alcohol and/or drug use evident? Yes No Unknown B: BARRIER INFORMATIONProperty fence present: Yes No Unk N/A Separate fence around pool Yes No Unk N/A Self-closing/Self-latching gate Yes No Unk N/A Other barriers/alarms present: Unknown/unable to access Sliding Door Alarm Other Barrier Access to Pool by Victim: Unknown Direct Access by Adult Direct Access by Child/no barriers or supervision Child brought in to water area by other person Pet door Explain how the victim got through the barrier(s): C: CLASSES/EMERGENCY PREPARATIONWas rescue equipment near water? NA Shepard’s hook life ring other None Unknown/not assessed Was rescue equipment near water: OtherDescribe Who initially performed CPR? supervisor bystander 9-1-1 / EMS personnel NA/CPR not performed Unknown other Who initially performed CPR: OtherDescribe Did victim ever take swim lessons or water safety classes? Yes No Unknown Victim transported to: DOA on Scene Narrative:CPS Referral made: Yes No Date: MM slash DD slash YYYY Reason: Environmental Health referralEH is notified for all green/dirty pools or when submersion occurs at community pool setting (apartment, condo, hotel, park…). Yes No NA Completed by: Email Address: Contact Phone: