UnitedStates Lifesaving Association
LifeguardAgency CertificationProgram
CertificationReview Form
This form should be filled out on your computer using Microsoft Word 2010 or a newer version of Word. It will not work properly in prior versions of Microsoft Word. Use your mouse and keyboard to input words, choose options, and check boxes.Then print the application and affix appropriate signatures and dates before mailing. If you are unable to use a computer with Microsoft Word 2010 or newer, contact for an alternative form.
Enter name ofapplying agency:Click here to enter agency name.
Click at right to select an option from drop down box:Choose an item.
Click at right to selectanoptionfrom drop down box:Choose an item.
This form is used tovalidate compliance ofa lifeguard agency applying tobe certified under the United StatesLifesaving Association Lifeguard Agency Certification Program. This form mustbe completed by an authorized agency representative. Application forms are updated regularly. Before completing this form,please make sure you have the mostrecent form by checking at in the Certification section. Applicants mustsubmit information in every section ofthis form.Ifan appropriate answer is not selected or inserted, the application is not complete. Once this form is complete, print a copy foryour records and submit a copy, with appropriate attachments, per instructions on the final page ofthe form.Whencomplete,mailthisform toPO Box 1266, SanMarcos, CA 92079-1266.Ifyouwish,youmaysendviaUSPSPriority orExpress Mail.
Title and Name ofAgency Director:Click here to enter text.
AgencyStreet Address or PO Box:Click here to enter text.
Agency City, State, Zip: Click here to enter text.
AgencyDirector'sTelephone:Click here to enter text.
Agency Director’s E-mail: Click here to enter text.
AgencyWebsite(ifany):Click here to enter text.
AgencyE-mail (ifany):Click here to enter text.
Agency Director’s Off-SeasonContact Info (ifseasonal): Click here to enter text.
Name of Person Completing This Form:Click here to enter text.
Address of Person Completing This Form:Click here to enter text.
Telephone Number of Person Completing This Form: Click here to enter text.
E-mail Address of Person Completing This Form: Click here to enter text.
For statistics gathering only: Does your agency conduct a Junior Lifeguard Program?Choose an item.
If yes, are all of your program instructors lifeguards from a USLA certified agency? Choose an item.
Initial Requirements for All Agencies
Minimum agerequiredforallhourlyand/orseasonallifeguardpersonnel(includingtrainees,ifany):Click to enter age.
NOTE:Aminimumageof16isrequiredforUSLALifeguardAgencyCertification.
Minimum agerequiredforallfull-time(year-round)lifeguardpersonnel(ifnone,write"NONE"):Click here to enter text.
NOTE: A minimum age of 18 is required for USLA Lifeguard Agency Certification.
Swimming Ability: The ability to swim 500 meters (550 yards) in 10 minutes or less over a measured course is required for certification. A swim test of under 500 meters is not permissible. Swim tests over 500 meters are encouraged, but times must be equivalent to or faster than the 500 meters in 10 minutes standard. If the swim test is combined with other physical testing, such as a run, the swim portion must be timed separately.
Howoftenareswimmingskillsofhourlyand/orseasonallifeguardpersonneltested?Click here to enter text.
Whatisthelengthofthetimedswimmingtestforhourlyand/orseasonallifeguards?Click here to enter text.
Whatisthemaximumtimeallowedtopassthisswimmingtest?Click here to enter text.
Does your agency employ full-time (year-round) lifeguard personnel?Choose an item.
If answer to above is yes, answer next three questions. If no, disregard the next three questions.
Howoftenareswimmingskillsoffull-time(year-round)lifeguardpersonneltested?Click here to enter text.
What is the length of the timed swimming test for full-time (year-round) lifeguards?Click here to enter text.
What is the maximum time allowed to pass this swimming test?Click here to enter text.
☐ I verify that our agency maintains a publicly available, written policy detailing our required swim test covering all lifeguards. NOTE: Policy must be attached to this application. See last page for details.
☐ I verify that our agency requires by policy that all lifeguards (including trainees prior to any assignment of lifeguard duties) maintain current certification as having successfully completed a course, accepted by the Federal Government or by the state government in the state of employment, in providing one person adult, two person adult, child and infant cardiopulmonary resuscitation (CPR), including obstructed airway training. NOTE: Applicant must attach a copy of agency policy on CPR training and standard course description (including course title) of the required course as provided by the certifying organization. See last page for details.
☐ I verify that our agency requires by policy that all hourly lifeguards (including trainees prior to any assignment of lifeguard duties) maintain current certification as having successfully completed a first aid course accepted by the Federal Government or by the state government in the state of employment. NOTE: Total first aid training must be no less than 21 hours, not including the time involved in CPR or other lifeguard training. Applicant must attach a copy of any agency policy and standard course description (including course title and total hours of instruction) of the full required first aid course of instruction. If the standard length of the formal first aid course is less than 21hours in length, applicant must attach a curriculum specifically detailing what additional first aid training is provided to meet the 21 hour requirement. This must be individually listed, including the number of hours of each training module. See last page for details.
☐ I verify that our agency has been conducting the lifeguard operations described here for at least one full season.
The year (and month if within one year) our agency first began operations was:Click here to enter text.
☐ I verify that all first aid and CPR instructors used by our agency are currently, properly authorized to teach the first aid and CPR course or courses taught to our lifeguard personnel.
☐ I verify that in addition to completing CPR and first aid training before any assignment as a lifeguard (and exclusive of that training) all lifeguards are trained in a formal course at least 40 hours in length, including all elements of the required USLA curriculum under one of the following methods (check one or both):
☐ All training is provided prior to any assignment as a lifeguard (preferred method).
☐ Formal training is spread over a (maximum) 30 day period. Trainees work only under the direct and immediate supervision (side-by-side in the same station or area) of a lifeguard with at least 1,000 hours of experience. Training hours, subjects, and instructors are documented for review.
☐ I verify that a medical doctor, or the doctor’s designated physician’s assistant or ARNP (advanced registered Nurse Practitioner),documents that all lifeguards employed by our agency possess adequate vision, hearing acuity, physical ability and stamina to perform duties of an open water lifeguard. NOTE: Recommended standards for medical evaluations can be found in Appendix A.
☐ I verify that any lifeguard who will be required to utilize scuba in the course of employment is, at a minimum, certified as a scuba diver at the basic level by a nationally recognized certifying agency. (If no lifeguard is required to utilize scuba, you may check this box.)
☐ I verify that Open Water Lifeguard Instructors (who oversee our agency lifeguard training) are required, at a minimum, to possess a high school diploma or equivalency certificate.
☐ I verify that lifeguards assigned to water surveillance are given no duties other than those directly related to public safety.
☐ I verify that the lead instructor(s) of our agency's lifeguard training are required to have lifesaving experience by having worked a minimum of 1,000 hours, compiled in no less than three seasons.
☐ I verify that all lifeguards are provided daily opportunities, conditions permitting, for activities such as swimming, rescue board training and running.
☐ I verify that subsequent to initial training being provided, all lifeguards are provided a minimum of 16 hours per year in formal training.
For agencies that employ some or all lifeguards full time, year-round, verify that the following three requirements are met. If not, do not check boxes and continue to next page.
☐ I verify that all full time lifeguards (employed year-round) are required by policy (attach copy), at a minimum, to be certified in a course which is equivalent to Department of Transportation First Responder.
Course title: Click here to enter text.
Certifying authority: Click here to enter text.
☐ I verify that full time, year-round lifeguard personnel must have worked a minimum of 1,000 hours as an open water lifeguard at the beaches of the hiring agency.
☐ I verify that full time, year-round lifeguard personnel, if any, are required, at a minimum, to possess a high school diploma or equivalency certificate.
MinimumEquipmentStandards
☐I verify that at least one rescue floatation device (RFD) is available for each lifeguard on duty.
☐I verify that masks and snorkels are readily accessible to mount an underwater search and rescue.
Number of masks and snorkels available:Click here to enter text.
☐I verify that binoculars are readily accessible in the beach area, and in each main tower and emergency vehicle.
☐I verify that marker buoys are readily accessible for submerged victim search and rescue.
☐I verify that swim fins for rescue are readily accessible to lifeguards, as appropriate according to local conditions.
☐I verify that a first aid kit adequate to treat minor injuries is available at each staffed lifeguard post.
☐I verify that a first aid kit to treat minor and major medical emergencies is available at each staffed beach area.
☐I verify that equipment to protect against blood borne pathogens consistent with OSHA requirements is available to all lifeguards.
☐I verify that spinal stabilization equipment, including spineboard, head and neck immobilization devices, and fastening devices is readily accessible at each staffed beach area.
☐I verify that oxygen is readily accessible at each staffed beach area and all lifeguard personnel are trained in its use.
The total number of oxygen delivery units maintained by our agency is:Click here to enter text.
☐I verify that a cardiac defibrillator (or defibrillators) is readily accessible at each staffed beach area, with personnel trained in its use. (This is highly recommended for all agencies, but required to achieve advanced certification.)
The total number of cardiac defibrillators maintained by our agency is:Click here to enter text.
☐I verify that equipment for lifeguards to communicate with the public at a distance (e.g. public address systems, whistles, megaphone(s), air horn(s), etc.) is provided at all locations staffed by lifeguards.
☐I verify that our agency provides equipment for lifeguard to lifeguard communication.
Describe:Click here to enter text.
☐I verify that equipment is provided for lifeguards to immediately activate local emergency medical services.
☐I verify that lifeguards are required to wear an easily identifiable uniform, denoting the wearer as a trained rescuer(e.g.: "Lifeguard," "Beach Patrol," "Marine Safety") and denoting the employing agency.
☐I verify that sunscreen is provided for use by all lifeguards.
☐I verify that equipment is provided to protect lifeguards from sun exposure.
☐I verify that Open Water Lifesaving, The United States Lifesaving Association Manual is provided to each trainee.
☐I verify that our agency maintains a system for documenting lifeguard activities consistent with USLA standards and that our annual statistical data is reported to the USLA Statistics Coordinator by March 1 each year.
Additional Requirements for Agencies Applying for Advanced Level Certification
☐I verify that Open Water Lifeguard Instructors (lead instructors of agency training programs) are required to have worked a minimum cumulative total of 2,000 hours of employment compiled in no fewer than five seasons as a seasonal lifeguard or above at a lifeguard agency certified as meeting the minimum recommended standards of USLA.
☐I verify that Open Water Lifeguard Instructors are required to have at least two seasons experience as instructors or assistant instructors of a program which meets the minimum recommended standards for USLA certification.
☐I verify that the lead instructor(s) of our agency's lifeguard training are required to be scuba certified.
☐I verify that all lifeguards, including trainees, are required to successfully complete a pre-employment test demonstrating adequate physical strength and stamina to perform the duties of an open water lifeguard.
☐I verify that all seasonal and/or hourly lifeguards, except trainees, are, at a minimum, required by policy (attach policy) to be certified as first responders in a course which is equivalent to Department of Transportation First Responder. If agency has no seasonal or hourly lifeguards, you may check this box and write, NO HOURLY EMPLOYEES in the course title area below.
Course title:Click here to enter text.
Certifying organization or authority:Click here to enter text.
☐I verify that our agency conducts drills such as mock rescues and other emergencies at least once per month which allow each employee some degree of participation.
☐I verify that seasonal and/or hourly lifeguards are certified as successfully completing a course consisting of a total of not less than 48 hours in open water lifesaving which meets the curriculum requirements of the United States Lifesaving Association. This shall not include the minimum training hours required for first aid or CPR. NOTE: This is in place of, rather than in addition to the regular requirement of 40 hours of instruction.
For agencies that employ some or all lifeguards full time, year-round, verify that the following requirement is met. If not, do not check box. Continue to next page.
☐I verify that all full time lifeguards (employed year round) are required by policy (attach policy) to be certified as Emergency Medical Technicians in the state of employment.
Course Curriculum Checklist
To comply with requirements of the USLA Lifeguard Agency Certification Program, an agency's training program for lifeguards must include all elements included in this checklist with the exception of those where an underlined statement allows an exception. By checking boxes, you verify that your lifeguard training program includes the described element.
Identify means provide a full explanation to students and take steps to validate their comprehension and retention.
Demonstrate means show students how to accomplish the skill and ensure that students can adequately demonstratean ability perform it.
☐Identify the importance of a lifeguard maintaining a position of safety when effecting a rescue.
☐Identify the appropriate method of entry for various types of water conditions, including the following. Training is not required and you need not check the surf box if the agency does not serve a surf beach.
☐Shallow water
☐Deep water
☐Unfamiliar water
☐Surf
☐Identify the characteristics of a proper approach to a victim.
☐Identify considerations when making contact with a victim.
☐Identify the appropriate victim approach for different rescue situations: front surface, rear surface or underwater.
☐Identify the value of an arm assist or cross-chest carry for a given rescue situation.
☐Identify appropriate methods of lifting and removing a victim from the water.
☐Identify the priority of resuscitation over removal of a victim from the water.
☐Identify the general principles of defense, release, and escape from a panicked victim.
☐Identify the advantages and disadvantages of using swim fins during rescues.
☐Identify the advantages and disadvantages of reaching, wading, and throwing assists.
☐Identify the need to assess for spinal injury prior to effecting a rescue or moving a victim.
☐Identify the physiological response and behavioral sequences in victim recognition.
☐Demonstrate stride jump, shallow water dive, and porpoising.
☐Demonstrate the heads-up breast stroke, heads-up crawl stroke, and quick reverse.
☐Demonstrate the front surface approach, rear surface approach, submerged victim approach, and level-off.
☐Demonstrate the arm assist and cross chest carry.
☐Demonstrate releases and escapes from a panicked victim or victims.
☐Demonstrate the donning and use of swim fins in rescue, if swim fins are used by the agency.
☐Demonstrate donning and clearing of mask and snorkel, and surface dive to recover a minimum 150 pound victim from a depth of at least ten feet of water.
☐Demonstrate proper spinal injury management during a rescue.
☐Identify the primary and secondary functions of a lifeguard.
☐Identify the need for policies and standard procedures.
☐Identify the role of public relations in lifeguarding.
☐Identify proper methods of communicating with the public.
☐Identify functions of tower systems, particularly those used by the employing agency.
☐Identify the uses of mobile vehicle support if used by the agency.
☐Identify the uses of both power and non-power vessel support.
☐Identify the correct way to interface with other local safety agencies including ambulance services, police, and rescue personnel. Identify the emergency plan to summon and utilize these agencies when needed.
☐Identify the importance of equipment maintenance.
☐Identify factors which increase the risk of legal action.
☐Identify the purpose of uniforms.
☐Identify the importance of in-service training.
☐Identify the need for skin and eye protection from environmental exposure.
☐Identify the risks of personal injury to lifeguards posed by trauma and biohazards, particularly during training and rescue responses.
☐Identify methods of promoting personal safety through stretching exercises, use of wetsuits and other protective gear, and the use of rescue equipment and victims as buffers from sources of injury.
☐Identify the need for and methods to access backup in emergencies.
☐Identify the various types of waves and the forces effecting their formation, if the agency serves a beach with wave action. (If no waves present, this box need not be checked.)
☐Identify the characteristics and means of recognizing the types of currents experienced in the waters served by theagency.