Diving accident report form
The UCLA Diving Medicine Center is very interested in data pertaining to your diving accident! Please provide us with this important information by filling out the following simple form:
(Your data will be kept confidential, and will be used for research purposes only!)
Personal information:

First name: Middle intial: Last name:

Gender: Male Female

Address: Street: City: State: Zip-code: Country:

Day-time telephone with area code:

Date and type of accident:

I am a: Snorkeler Scubadiver Professional diver

The accident occurred on: Month Day Year

The dive was in

Mechanism of accident:

The accident involved (check all that apply):
Technical problems with equipment
Emergent ascent
Marine wildlife
Hypothermia

Help received:

I received help and/or treatment by (check all that apply):
My diving buddy
My diving instructor
Local emergency medical services or law enforcement
A local hospital or physician
A hyperbaric chamber

Narrative description:

Please provide us with a brief description of the events:
Ready to submit?

Thank you for your time and effort! All done? Then please submit your form. Or, if you wish to clear the form, please press the reset button.

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