Shallow Water Blackout Incident Report

Please submit relevant information below if an underwater hypoxic blackout has happened to you or someone you know.

Your Name

First Name

Last Name

Your Email Address

Name of Swimmer

First Name

Last Name

Your Phone Number

Optional

(###)

###

####

If you are not the swimmer who experienced the blackout, what is your relation to the swimmer?

Date of Incident

YYYY

Where did the incident take place?

Type of waterfront, name of facility, city and state

Describe the incident

Please share any/all relevant details

Did the victim survive the incident? If so, did they recover? Are there any lasting injuries?

Can you share any news article links or social media posts about this incident?

Please add relevant links below

Would you like to be contacted by our team?

Would you like for this story to be added on our website?

Either a survivor story, or have us post a memorial to your loved one

Is there a specific way that we can help and/or support you?

We will never share your information with a third party.