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pdfU.S. DEPARTMENT OF HOMELAND SECURITY
U. S. COAST GUARD
CG-3865 (Rev. 12-06)
BOATING ACCIDENT REPORT
FORM APPROVED
OMB NO. 1625-0003
EXPIRATION DATE
THE OPERATOR OF A VESSEL IS REQUIRED TO SUBMIT A REPORT IN WRITING TO THE STATE REPORTING AUTHORITY WHEN AS A RESULT
OF AN OCCURRENCE THAT INVOLVES THE VESSEL OR ITS EQUIPMENT: (1) A PERSON DIES; OR (2) A PERSON IS INJURED AND REQUIRES
MEDICAL TREATMENT BEYOND FIRST AID; OR (3) DAMAGE TO THE VESSEL AND OTHER PROPERTY TOTALS $2,000 OR MORE OR THERE IS A
COMPLETE LOSS OF THE VESSEL; OR (4) A PERSON DISAPPEARS FROM THE VESSEL UNDER CIRCUMSTANCES THAT INDICATE DEATH OR
INJURY. REPORTING AUTHORITIES MAY REQUIRE REPORTS OF PROPERTY DAMAGE LESS THAN $ 2,000. THIS REPORT MUST BE SUBMITTED
WITHIN 48 HOURS OF THE OCCURRENCE IF A PERSON DIES, IS INJURED, OR DISAPPEARS FROM THE VESSEL. THE REPORT MUST BE
SUBMITTED WITHIN 10 DAYS OF THE OCCURRENCE IF THERE IS ONLY DAMAGE TO THE VESSEL AND OTHER PROPERTY.
THE OWNER OF THE VESSEL SHALL SUBMIT THIS REPORT TO THE STATE REPORTING AUTHORITY IF THE OPERATOR CANNOT.
OVERALL ACCIDENT INFORMATION – TO BE COMPLETED BY THE OPERATOR OF THIS VESSEL (VESSEL A)
STATE
DATE OF ACCIDENT
TIME
AM
NUMBER OF VESSELS INVOLVED
PM
COUNTY
LOCATION ON THE WATER
NEAREST CITY OR TOWN
NAME OF BODY OF WATER
WEATHER FORECASTS / REPORTS AVAILABLE TO AND USED BY THE OPERATOR BEFORE AND DURING USE OF THE VESSEL
WEATHER
WATER CONDITIONS
(CHECK ALL THAT APPLY))
CLEAR
RAIN
WIND
VISIBILITY
DAY
CALM (WAVES LESS THAN 6”)
NONE
CHOPPY (WAVES 6” TO 2’)
LIGHT (0 - 12 MPH)
NIGHT
GOOD
CLOUDY
SNOW
ROUGH (WAVES 2’ TO 6’)
MODERATE (13 - 24 MPH)
FOG
HAZY
VERY ROUGH (GREATER THAN 6’)
STRONG (25 - 54 MPH)
FAIR
YES
NO
ESTIMATED TEMPERATURE
(DEGREES FAHRENHEIT)
AIR
(
)
WATER
(
)
STRONG CURRENT
NO
YES
POOR
STORM (55 MPH AND OVER)
OPERATOR INFORMATION – TO BE COMPLETED BY THE OPERATOR OF VESSEL A
NAME
LAST
FIRST
MIDDLE INITIAL
ADDRESS
STREET
CITY
STATE
TELEPHONE NUMBER
(
)
DATE OF BIRTH (MO/DAY/YR)
EXPERIENCE OPERATING THIS VESSEL
FEMALE
AGE IN YEARS
FORMAL INSTRUCTION (TRAINING) COURSE COMPLETED IN BOATING SAFETY
UNDER 10 HOURS
10 TO 100 HOURS
OVER 500 HOURS
OTHER (SPECIFY)
100 TO 500 HOURS
NONE
YES
STATE COURSE
USCG AUXILIARY
U.S. POWER SQUADRONS
OTHER (SPECIFY)
INTERNET (SPECIFY)
OPERATOR WEARING A USCG APPROVED LIFE JACKET AT THE
TIME OF THE ACCIDENT
MALE
ZIP CODE
OPERATOR WEARING A SAFETY LANYARD (ENGINE SHUT OFF DEVICE) AT THE
NO
TIME OF THE ACCIDENT
YES
NO
INFORMATION ASSOCIATED WITH VESSEL A – TO BE COMPLETED BY THE OPERATOR OF VESSEL A
NUMBER OF PERSONS DISAPPEARED
NUMBER OF PERSONS WHO DIED
WAS VESSEL A TOTAL LOSS
NUMBER OF PERSONS INJURED REQUIRING MEDICAL TREATMENT BEYOND FIRST AID
YES
AMOUNT OF DAMAGE TO THIS VESSEL $
AMOUNT OF DAMAGE TO OTHER PROPERTY $
TOTAL PROPERTY DAMAGE AMOUNT $
DESCRIBE VESSEL DAMAGE
DESCRIBE OTHER PROPERTY DAMAGE
VESSEL REGISTRATION NUMBER
HULL IDENTIFICATION NUMBER (HIN)
VESSEL NAME
NAME OF VESSEL MANUFACTURER
VESSEL MODEL
YEAR BUILT
VESSEL BEAM WIDTH AT WIDEST POINT (FEET AND INCHES)
DEPTH FROM TRANSOM (STERN) TO KEEL (BOTTOMMOST POINT) OF VESSEL
VESSEL LENGTH (FEET AND INCHES)
VESSEL DOCUMENTATION NUMBER
RENTED VESSEL
YES
NO
NO
NUMBER OF PERSONS ON BOARD VESSEL
CURRENT VESSEL SAFETY CHECK (VSC) DECAL
USCG APPROVED LIFE JACKETS ON BOARD THE VESSEL
LIFE JACKETS ACCESSIBLE (CAPABLE OF BEING REACHED)
YES
YES
NUMBER OF VESSEL OCCUPANTS (OPERATOR AND PASSENGERS)
WEARING LIFE JACKETS AT THE TIME OF THE ACCIDENT
YES
NO
NUMBER OF PERSONS BEING TOWED
NO
OPERATOR ARRESTED DUE TO BOATING UNDER
FIRE EXTINGUISHERS
NO
THE INFLUENCE (BUI) FOR THIS ACCIDENT ONLY
ON BOARD
YES
NO
OPERATOR BLOOD ALCOHOL CONCENTRATION
(BAC) LEVEL
YES
NO
USED
YES
NO
VESSEL INFORMATION – TO BE COMPLETED BY THE OPERATOR OF VESSEL A
TYPE OF VESSEL
TYPE OF HULL MATERIAL
AIR BOAT
OPEN MOTORBOAT
AUXILIARY SAIL
PERSONAL
CABIN MOTORBOAT
WATERCRAFT (PWC)
CANOE
PONTOON BOAT
HOUSEBOAT
ROWBOAT
INFLATABLE
SAIL (ONLY)
KAYAK
OTHER (SPECIFY)
FIBERGLASS
TYPE OF ENGINE USED TO PROPEL
THE VESSEL
NUMBER OF ENGINES
OUTBOARD
ALUMINUM
ENGINE (S) USED TO
PROPEL THE VESSEL
STERNDRIVE - (I/O)
STEEL
INBOARD
WOOD
RUBBER / VINYL / CANVAS
TOTAL HORSEPOWER
NONE
KEVLAR
PLASTIC
(ROYALEX, POLYETHYLENE)
JET BOAT
OTHER (SPECIFY)
TYPE OF PROPULSION
TYPE OF FUEL
PROPELLER
WATER JET
GASOLINE
MANUAL
SAIL
DIESEL
AIR THRUST
ELECTRIC
OTHER (SPECIFY)
OPERATION AT TIME OF ACCIDENT
ACTIVITY AT TIME OF ACCIDENT
TYPE OF ACCIDENT (NUMBER BY ORDER OF OCCURRENCE)
FIRE / EXPLOSION
(FUEL)
AT ANCHOR
COMMERCIAL ACTIVITY
CAPSIZING
BEING TOWED
FISHING
CARBON MONOXIDE EXPOSURE
CHANGING DIRECTION
FISHING TOURNAMENT
COLLISION WITH FIXED OBJECT
FIRE / EXPLOSION
(OTHER THAN FUEL)
CHANGING SPEED
FUELING
HUNTING
COLLISION WITH FLOATING
OBJECT
FLOODING / SWAMPING
CRUISING
DOCKING / UNDOCKING
MAKING REPAIRS
DRIFTING
RACING
COLLISION WITH COMMERCIAL
VESSEL
LAUNCHING
SCUBA DIVING / SNORKLING
PERSON DEPARTED VESSEL
STRUCK BY A VESSEL
ROWING / PADDLING
STARTING ENGINE
PERSON EJECTED FROM VESSEL
SAILING
SWIMMING
ELECTROCUTION
STRUCK BY PROPELLER
OR PROPULSION UNIT
TIED TO DOCK / MOORING
TUBING
FALL WITHIN A VESSEL
STRUCK SUBMERGED
OBJECT
TOWING ANOTHER VESSEL
WATER SKIING
FALL ON A VESSEL
OTHER (SPECIFY)
WHITEWATER ACTIVITY
OTHER (SPECIFY)
FALLS OVERBOARD
DID THE ACCIDENT RESULT IN A
“HIT AND RUN”
YES
COLLISION WITH VESSEL
GROUNDING
SINKING
SKIER MISHAP
VESSEL SPEED AT THE TIME OF THE ACCIDENT
NO
NOT MOVING
UNDER 10 MPH
10 - 20 MPH
21 - 40 MPH
OVER 40 MPH
CONTRIBUTING FACTORS (CHECK ALL THAT APPLY)
SPECIFY “EQUIPMENT FAILURE”
ALCOHOL USE
NO PROPER LOOKOUT
AUXILIARY EQUIPMENT FAILURE (e.g., GENERATOR)
CARELESS/RECKLESS OPERATION
NAVIGATION AID MISSING / INADEQUATE
COMMUNICATION EQUIPMENT FAILURE
OPERATOR INATTENTION
FIRE EXTINGUISHER NOT SERVICEABLE
OPERATOR INEXPERIENCE
SAIL DISMASTING
OVERLOADING
SEAT BROKE LOOSE
PASSENGER / SKIER BEHAVIOR
SOUND PRODUCING EQUIPMENT FAILURE
RESTRICTED VISION
VISUAL DISTRESS SIGNALS FAILED
CONGESTED WATERS
DAM / LOCK
DRUG USE
EQUIPMENT FAILURE
EXCESSIVE SPEED
FAILURE TO VENT
FORCE OF WAKE / WAKE
RULES OF THE ROAD VIOLATION
HAZARDOUS WATERS
SHARP TURN
HULL FAILURE
STANDING / SITTING ON GUNWHALE, BOW,
OR TRANSOM
IGNITION OF SPILLED FUEL OR VAPOR
IMPROPER ANCHORING
STARTING IN GEAR
SPECIFY “MACHINERY FAILURE”
ELECTRIC SYSTEM FAILURE
ENGINE FAILURE
FUEL SYSTEM FAILURE
SUDDEN MEDICAL CONDITION
(HEART ATTACK, STROKE, SEIZURE)
SHIFT FAILURE
IMPROPER LOADING
FAILURE TO YIELD
WEATHER (HEAVY)
THROTTLE FAILURE
LACK OF / OR IMPROPER BOAT LIGHTS
LACK OF / IMPROPER SKI OBSERVER
VENTILATION SYSTEM FAILURE
MACHINERY FAILURE
OTHER (SPECIFY):
STEERING SYSTEM FAILURE
INJURED VICTIMS ASSOCIATED WITH VESSEL A (IF MORE THAN 1 INJURY, ATTACH ADDITIONAL FORMS)
NAME
LAST
FIRST
ADDRESS
STREET
CITY
AGE OF VICTIM
DATE OF BIRTH
STATE
INJURY REQUIRING MEDICAL TREATMENT BEYOND FIRST AID
YES
NO
WAS INJURED VICTIM ADMITTED TO A HOSPITAL
YES
NO
WAS A LIFE JACKET WORN BY THE VICTIM
YES
NO
WAS THE LIFE JACKET WORN BY THE VICTIM INFLATABLE
YES
NO
TYPE OF LIFE JACKET WORN
TYPE I
MIDDLE INITIAL
TYPE II
TYPE OF PRIMARY INJURY (CHECK ONE IN EACH COLUMN BELOW)
BODY REGION (CHECK ONE)
ABRASION / CONTUSION (BRUISE)
NECK
AMPUTATION
BACK
CARBON MONOXIDE POISONING
CHEST / ABDOMEN
CONCUSSION / BRAIN INJURY
SHOULDER / ARM
DISLOCATION
NO
WRIST / HAND / FINGER
FRACTURE / BROKEN BONE
HEART ATTACK
TYPE V
YES
NO
INJURY CAUSED BY (CHECK ALL THAT APPLY)
EXPOSURE TO ELEMENTS
YES
NATURE OF INJURY (CHECK ONE)
HEAD / FACE
TYPE III
TYPE IV PERSONAL FLOTATION DEVICE (THROWABLE) USED
ZIP CODE
IMPACT WITH FIXED / FLOATING OBJECT
YES
NO
PELVIS / HIP
IMPACT WITH VESSEL
YES
NO
KNEE / LEG
INTERNAL ORGAN INJURY
ANKLE / FOOT / TOE
LACERATION / CUT
IMPACT WITH WATER
YES
NO
BEING STRUCK BY THE VESSEL
YES
NO
SPINAL CORD INJURY
BEING STRUCK BY THE PROPELLER
YES
NO
SPRAIN / STRAIN
YES
NO
YES
NO
OTHER (PLEASE SPECIFY):
ALCOHOL USE APPARENT BY THE INJURED VICTIM
BLOOD ALCOHOL CONCENTRATION (BAC) LEVEL:
DRUG USE APPARENT BY THE INJURED VICTIM
SPECIFY THE TYPE (S) OF DRUGS BEING USED:
VICTIM STATUS AT THE TIME OF THE ACCIDENT
OPERATOR
PASSENGER
PRIMARY INJURY:
PRIMARY INJURY:
BODY REGION:
OTHER (SPECIFY):
NATURE OF INJURY:
OTHER (SPECIFY):
SECONDARY INJURY:
SECONDARY INJURY:
BODY REGION:
OTHER (SPECIFY):
NATURE OF INJURY:
OTHER (SPECIFY):
VICTIM ACTIVITY AT THE TIME OF THE ACCIDENT
SWIMMER
WATER SKIER
OTHER (SPECIFY)
FISHING
HUNTING
SCUBA DIVING / SNORKLING
SWIMMING
TUBING
WATERSKIING
OTHER (SPECIFY):
DECEASED VICTIMS ASSOCIATED WITH VESSEL A (IF MORE THAN 1 DEATH, ATTACH ADDITIONAL FORMS)
NAME
LAST
FIRST
ADDRESS
STREET
CITY
AGE OF VICTIM
DATE OF BIRTH
CAUSE OF DEATH
WAS VICTIM STRUCK BY THE PROPELLER
YES
DROWNING
STATE
NO
WAS VICTIM STRUCK BY THE VESSEL
TRAUMA
CARBON MONOXIDE
POISONING
YES
MIDDLE INITIAL
NO
VICTIM STATUS AT THE TIME OF THE ACCIDENT
ZIP CODE
WAS A LIFE JACKET WORN BY THE VICTIM
YES
NO
WAS THE LIFE JACKET WORN BY THE VICTIM INFLATABLE
YES
NO
TYPE OF LIFE JACKET WORN
TYPE I
TYPE II
TYPE III
TYPE IV PERSONAL FLOTATION DEVICE (THROWABLE) USED
TYPE V
YES
NO
VICTIM ACTIVITY AT THE TIME OF THE ACCIDENT
HEART ATTACK
OPERATOR
FISHING
HUNTING
SCUBA DIVING / SNORKLING
HYPOTHERMIA
PASSENGER
SWIMMING
TUBING
WATERSKIING
SWIMMER
OTHER (SPECIFY)
ELECTROCUTION
OTHER (SPECIFY)
WATER SKIER
OTHER (SPECIFY):
DISAPPEARANCE
YES
ALCOHOL USE APPARENT BY THE VICTIM
NO
BLOOD ALCOHOL CONCENTRATION (BAC) LEVEL:
YES
NO
DRUG USE APPARENT BY THE VICTIM
TYPE(S) OF DRUGS BEING USED:
YES
NO
ACCIDENT DESCRIPTION
DESCRIBE WHAT HAPPENED (SEQUENCE OF EVENTS) AND CONTRIBUTING FACTORS. INCLUDE FAILURE OF MACHINERY OR EQUIPMENT. INCLUDE A
DIAGRAM AND CONTINUE ON ADDITIONAL SHEETS IF NECESSARY. INCLUDE ANY INFORMATION REGARDING THE INVOLVEMENT OF ALCOHOL AND / OR
DRUGS IN CAUSING OR CONTRIBUTING TO THE ACCIDENT. INCLUDE ANY DESCRIPTIVE INFORMATION ABOUT THE USE OF PERSONAL FLOATATION DEVICES
(PFDS). PLEASE DO NOT LIST ANY PERSONAL IDENTIFIERS IN THIS SECTION -- SUCH AS NAMES OF INDIVIDUALS, TELEPHONE NUMBERS, STREET ADDRESSES,
ETC. REFER TO INDIVIDUALS AS OPERATOR A, OPERATOR B, VICTIM 1, VICTIM 2, ETC. AND TO THE VESSEL(S) INVOLVED AS VESSEL A, VESSEL B, ETC. FOR
EXAMPLE: OPERATOR OF VESSEL (A) DID NOT HAVE A PROPER LOOKOUT AND RAN INTO VESSEL (B) INJURING VICTIMS (1) AND (2) ON VESSEL (B).
WITNESSES FOR THIS ACCIDENT (IF MORE THAN ONE – LIST ON A SEPARATE SHEET)
NAME
LAST
FIRST
TELEPHONE NUMBER (
ADDRESS
STREET
CITY
STATE
)
ZIP CODE
OWNERS OF PROPERTY INVOLVED (IF MORE THAN ONE – LIST ON A SEPARATE SHEET)
NAME
LAST
FIRST
TELEPHONE NUMBER (
ADDRESS
STREET
CITY
STATE
)
ZIP CODE
OWNER INFORMATION FOR VESSEL A
NAME
LAST
FIRST
ADDRESS
STREET
CITY
TELEPHONE NUMBER (
)
STATE
MIDDLE INITIAL
ZIP CODE
PERSON SUBMITTING THIS REPORT FOR VESSEL A
STATUS OF PERSON COMPLETING THIS REPORT
OPERATOR
OWNER
OTHER (OPERATOR AND OWNER ARE UNABLE TO COMPLETE THIS REPORT) -- SPECIFY WHO IS COMPLETING THIS REPORT:
NAME
LAST
FIRST
TELEPHONE NUMBER (
ADDRESS
STREET
CITY
STATE
SIGNATURE
)
ZIP CODE
DATE SUBMITTED
OPERATOR OR OWNER OF THE OTHER VESSEL (VESSEL B) INVOLVED IN THE ACCIDENT
EACH VESSEL OPERATOR OR OWNER IS REQUIRED TO FILE A SEPARATE AND COMPLETE REPORT
NAME
LAST
FIRST
TELEPHONE NUMBER (
ADDRESS
STREET
CITY
STATE
)
ZIP CODE
FOR STATE AGENCY USE ONLY
OFFICIAL
LAST NAME
PRIMARY CAUSE OF THE ACCIDENT
SIGNATURE OF REVIEWING OFFICIAL
FIRST
TELEPHONE NUMBER (
)
SECONDARY CAUSE OF THE ACCIDENT
DATE REVIEWED
An Agency may not conduct or sponsor and a person is not required to respond to an information collection, unless it displays a currently valid OMB Control Number. The Coast
Guard estimates that the average burden for this report form is 30 minutes. You may submit any comments concerning the accuracy of this burden estimate or any suggestions
for reducing the burden to: Commandant (CG-3PCB), U.S. Coast Guard, Washington, DC 20593-0001 or Office of Management and Budget, Paperwork Reduction Project
(1625-0003), Washington, DC 20593.
File Type | application/pdf |
File Modified | 2007-02-26 |
File Created | 2007-02-22 |