Boating Accident Report

U.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

CONGESTED WATERS

OPERATOR INATTENTION

FIRE EXTINGUISHER NOT SERVICEABLE

DAM / LOCK

OPERATOR INEXPERIENCE

SAIL DISMASTING

DRUG USE

OVERLOADING

SEAT BROKE LOOSE

EQUIPMENT FAILURE

PASSENGER / SKIER BEHAVIOR

SOUND PRODUCING EQUIPMENT FAILURE

EXCESSIVE SPEED

RESTRICTED VISION

VISUAL DISTRESS SIGNALS FAILED

FAILURE TO VENT

RULES OF THE ROAD VIOLATION

FORCE OF WAKE / WAKE

SHARP TURN

HAZARDOUS WATERS

STANDING / SITTING ON GUNWHALE, BOW,
OR TRANSOM

HULL FAILURE
IGNITION OF SPILLED FUEL OR VAPOR

STARTING IN GEAR

SPECIFY “MACHINERY FAILURE”
ELECTRIC SYSTEM FAILURE
ENGINE FAILURE
FUEL SYSTEM FAILURE

SUDDEN MEDICAL CONDITION
(HEART ATTACK, STROKE, SEIZURE)

SHIFT FAILURE

IMPROPER ANCHORING
IMPROPER LOADING

WEATHER (HEAVY)

THROTTLE FAILURE

LACK OF / OR IMPROPER BOAT LIGHTS

OTHER (SPECIFY):

VENTILATION SYSTEM FAILURE

MACHINERY FAILURE

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
LACERATION / CUT
SPINAL CORD INJURY

IMPACT WITH WATER

YES

NO

ANKLE / FOOT / TOE

BEING STRUCK BY THE VESSEL

YES

NO

OTHER (SPECIFY):

BEING STRUCK BY THE PROPELLER

YES

NO

SPRAIN / STRAIN
OTHER (SPECIFY):

OTHER (PLEASE SPECIFY):
ALCOHOL USE APPARENT BY THE INJURED VICTIM

YES

NO

YES

NO

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

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 ACCDENT (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.