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Sample Swim Ability and Swim Comfort Assessment Questionnaire Form

Prior to participation in watercraft activities, teachers must be aware of all students' swim ability and swim comfort. The sample questionnaire is a tool that may be used by the teacher when gathering information from the parent/guardian about a student's swim ability, swim experience, and comfort in various bodies of water in which the activity takes place (e.g., pools/ponds/lakes and rivers). The tool is meant to be used in curricular, intramural and interschool settings.

Student’s Name:
Date of Completion of Assessment:

1. Swim Ability (Certifications acquired):

Check all applicable boxes

Has the student participated in a certified swim instruction program (e.g., swimming lessons at a municipal pool, formal swim instruction with a qualified Aquatic Instructor)?

Yes
No

If yes, location of Swim instruction:

Pool
Pond/lake/river

Certified Swim Programs and/or Certifications

Check all applicable boxes and add detailed information.

Certification (for example, Bronze Star, Bronze Medallion)
Detailed information on Certification(s) (for example, Bronze Star, Bronze Medallion):
Swim Program (for example, Swimmer 1, Swim Kids 1)
Detailed information of Swim Program(s) (for example, Swimmer 1, Swim Kids 1):
None

Provider:

Recognized Swim Organization (for example, Red Cross, YMCA)
Other:
Please provide other information:

2. Swim Comfort (Experience):

Check all applicable boxes

Pool environment (for example, backyard, municipal, YMCA)

a. Type of experience

None (for example, has never been in a pool)
Some/limited (for example, infrequently and only in shallow end, playing/splashing/wading)
Experienced (for example, frequently and in deep end, treading water, swimming without assistance)

b. Comfort level

Uncomfortable (for example, the student can hold on to the wall, let go for brief periods of time)
Some/limited comfort (for example, the student can swim without fear when close to the wall or with others)
Moderate comfort (for example, the student can enter the water without fear, when water is calm, and when with others)
Confident (for example, the student can enter and swim without fear anytime, submerge, tread water and swim with ease)
I don’t know

Pond, Lake, or River Environment

c. Type of experience

None (for example, the student has never been in a pond, lake, or river)
Some/limited (for example, the student stays near shore or beach, in shallow water waist level or less, splashing/wading)
Experienced (for example, the student can move away from shore, swim in deep water above shoulders: tread water, swim without assistance, jump/dive and swim to shore)

d. Comfort level

Uncomfortable (for example, the student is only comfortable when wearing a Personal Floatation Device (PFD) or lifejacket)
Some/limited comfort (for example, the student stays close to a dock, holds on to the dock/raft, can let go for brief periods of time)
Moderate comfort (for example, the student can enter the water and swim without fear when close to a dock/raft, or when supervised or when swimming with others)
Confident (for example, the student can enter water and swim without fear anytime, submerge, tread water and swim with ease)
I don’t know

Additional Skills and/or Certifications for Pond, Lake, or River

Check all applicable boxes and add detailed information.

Paddling skills:

Has the student participated in a paddling activity (for example, Canoeing, Kayaking, Stand Up Paddleboarding)

Yes
No
Certifications earned (for example, Ontario Recreational Canoeing and Kayaking Association (ORCKA) Level 1 - 4, Paddle Canada Basic Lake Skills)
Detailed information on Certification(s) earned:
First Aid (for example, Emergency First Aid, Standard First Aid, CPR-C)
Detailed information of First Aid:
Other
Please provide other information:

3. Other

List any additional information that the teacher should know about the student’s swim ability, swim comfort, and experience in, on or around water.
Parent/Guardian Signature:
Date:
Student’s Signature:
Date: