Shallow Water Blackout Incident Report

The intent of this report is to create a central repository to record incidents of a drowning or near-drowning after the swimmer experienced an underwater blackout. While not scientific we are attempting to capture the magnitude of shallow water blackouts. We will follow-up with each respondent (Recorder) to verify the information submitted. If we are unable to do so we will remove the incident from this report, which we will update after each incident is verified. Please provide as much of the following information as possible.

Swimmer's Name

First Name

Last Name

Was the swimmer a victim or survivor of SWB?

Swimmer's age:

Date of incident:

Location of the incident:

Swimmer’s activity (see key below):

What was the total amount of active time the individual was in the water prior to the incident?

If the individual was involved with intentional breath-holding activities – how long?

If the individual was performing intentional breath-holds how many did they do?

If the individual was not performing intentional breath-holding prior the incident what were they doing?

Were there any other contributing factors associated with the drowning?

Name of Reporter:

First Name

Last Name

Relation to victim/survivor:

Email address:

*Activity refers to what the individual was doing at the time of the incident. Please use the following key:

· Competitively swimming and/or training – CS

· Non-competitive (recreation) swimming - NCS

· Free diving – FD

· Military training - MT

· Playing breath-holding games - BHG

· Snorkeling – S

· Spearfishing – SF