Medical Exam - Diving Accident

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DIVING ACCIDENT
NAME OF DECEDENT:
This form is to be completed in addition to the ROD form in these guidelines
DIVER PROFILE
FIRST CONTACT:
CERTIFIED:
CERT. LEVEL:
YEARS DIVING:
TOTAL DIVES MADE:
DIVES IN LAST 12 MONTHS:
EXPERIENCE LEVEL:
SIGNS DIVER KNEW S/HE WAS IN DISTRESS:
DIVE CONDITIONS
LOCATION:
NEW DIVE SITE:
ALTITUDE:
WATER ENVIRONMENT:
WATER TEMPERATURE:
CURRENT:
WATER DEPTH:
VISIBILITY:
WAVE HEIGHT:
AMOUNT OF SURGE:
BOTTOM TYPE:
ENTRY:
NUMBER IN DIVE GROUP:
TYPE OF SUIT:
DIVE ACTIVITY:
SPECIALTY DIVE:
DIVER HEALTH
FATIGUE:
PHYSICALLY FIT:
MENTAL STATUS:
PRE-DIVE HEALTH:
PREVIOUS DIVE ACCIDENTS:
EQUIPMENT & OTHER DIVE PROBLEMS
IF KNOWN, DID EQUIPMENT HAVE ANY DEFECTS?
WAS THE DECEDENT:
ENTANGLED
TRAPPED
IF YES, DESCRIBE:
DID THE DECEDENT EXPERIENCE:
RAPID ASCENT
BUOYANCY PROBLEM
NITROGEN NARCOSIS
IF YES, EXPLAIN:
WEIGHT BELT
LBS/KG DROPPED
DIVE PROFILE
SINGLE DIVE:
DECOMPRESSION DIVING
LAST DIVE TRIP/SERIES:
USING A COMPUTER?
TYPE OF COMPUTER:
DEPTH 1:
B TIME 1
(MIN) SURFACE INTERVAL 1
DEPTH 2:
B TIME 2
(MIN) SURFACE INTERVAL 2
DEPTH 3:
B TIME 3
(MIN) SURFACE INTERVAL 3
RECOVERY/FIRST AID
WHEN DID PROBLEM OCCUR?
(MIN) WHAT DEPTH?
(FSW)
SEARCH BEGAN IMMEDIATELY:
AFTER
(HRS)
(MINS)
BODY RECOVERED AFTER:
(DAYS)
(HOURS)
USCG ASSISTANCE:
MEDIVAC:
IF YES, LIST AGENCY/CONTACT:
CPR DONE:
IF YES, EXPLAIN WHAT WAS DONE
OXYGEN AVAILABLE:
OXYGEN ADMINISTERED:
The Divers Alert Network, Box 3823, Duke University Medical Center, Durham, North Carolina 27710 (919 -684-2948 or 919 -684-8111) may be helpful in guiding you in this investigation. A copy of the autopsy report will be sent to DAN.
BE SURE TO CHECK WITH THE CENTRAL OFFICE ON WHAT TO DO WITH THE DIVING EQUIPMENT
NAME OF INVESTIGATOR
DMI#