Diving Incident Reporting Form

Directions: Use this form for anonymous reporting of diving incidents, near misses, and other diving safety concerns. Diving accidents and injuries should be reported directly to the Divers Alert Network (DAN).

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If you prefer, you may print out the following form and mail your report to:

Scuba STAR Network, 121 Adobe Casa Court, Tavernier, FL 33070

                   Diving Incident Reporting Form

1) Location where incident/accident occurred:

 

2) Date/Time:



3) This report describes an incident that was primarily (check one):


        __ Equipment-related (failure or malfunction)

        __ Procedure-related (technique, procedure, or training-related)
 
        __ Environment-related (conditions, marine life, etc.)

        __ Other

 

4) The activity ongoing at the time is best described as (check one):

        __ Recreational diving

        __ Technical Diving

        __ Training 

 

5) Describe what happened:

Note: If this was an equipment-related incident, please provide as much detail as possible regarding the specific equipment involved (Manufacturer, model, serial number, etc.) Include depth at which the incident occurred, and prevailing conditions.

 

6) Did this incident or accident involve a diving specialty, such as night diving, wreck diving, ice diving, etc.?

 

7) Were the participants trained and certified for the activity being conducted?

 

8) Describe any recommendations you would make as a result of this situation:

 

9) Reporter Information:

 

Certification (check one):

      ___ Student

      ___ Open water

      ___ Advanced

      ___ Rescue Diver

      ___ Divemaster/Divecon

      ___ Assistant Instructor

      ___ Instructor
 
      

Experience:         Total dives: _____

                        Number of dives in past year: _____

                        Number of dives within past week prior to incident/accident: ____


 
Thank you for submitting your report. We look forward to serving your safety needs!