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Get Pool Incident Report

) 673-0451 FAX (971) 673-0457 This report must be completed for every physiciantreated accident or any drowning at a public swimming pool. It is the responsibility of the pool operator to submit the completed form promptly to the Oregon Health Authority, Public Pool Program, 800 NE Oregon, Portland, OR 97232-2162 Date of Incident Time: am pm Accident ID # YYYY MMDD - County # Official Use Only Victim Information First Name Address MI Number Last Name Street City or Town Apt.# Sta.

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