Form CG-3865 Boating Accident Report

U.S. Dept. of Homeland Security

Recreational Boating Accident Report

U.S. Coast Guard CG-3865 (Rev. 03-08)

OMB No: 1625-0003
Expires:

NOTE: each boat operator/owner involved in an accident should submit a separate report.
Estimated report form completion time: 30 min
For each question below, please provide answers IF APPLICABLE AND IF KNOWN, otherwise leave blank.
REPORT SUBMISSION
Report required because (select all that apply):
… At least one person in this accident died :
If so, how many?

To be submitted within:
48 hours (if injury, disappearance or death)
10 days (if boat/property damage only )

… At least one injured person in this accident required or was in need of
treatment beyond first aid:
If so, how many?
… At least one person in this accident disappeared and has not
yet been recovered:
If so, how many?

To be submitted to:
(Local State Reporting Authority)

… All boat and other property damage (e.g., fishing/hunting gear) caused
by this accident totaled (or likely totaled) $2,000 or more:
Approximate value of damage to your boat:
$
Approximate value of damage to your other property:
$
… Your or another boat in this accident was (or likely was) a total loss

Town

Report submitted by (select all that apply):
… Boat Operator (required if possible)
… Boat Owner (if operator unable, or same as operator)
… Other (describe):
First name:

ST 12345
Phone: 111-222-3333
You may submit any comments concering the the accuracy of the burden estimate or
any suggestions for reducing the burden to: Commandant (CG-5422), U.S. Coast
Guard, Washington, DC 20593-0001 or Office of Management and Budget,
Paperwork Reduction Project (1625-0003), Washington, DC 20503.

For State Agency Use Only
First name:
Last name:
Phone:

Last name:
Primary cause of accident:

Phone:

-

-

ACCIDENT SUMMARY
WHEN
Date:
Time:

mm/dd/yy
:

ACCIDENT DESCRIPTION
Briefly describe this accident (attach extra pages if necessary):

| am | pm (select one)

WHERE
Body of water name:
Location (on water)
description:

DAMAGE TO YOUR BOAT
Briefly summarize any damage to your boat:

Nearest city/town:
County:
State:
YOUR BOAT - PEOPLE
# people on board (including operator):
# people being towed (e.g., on tubes, skis):
# people wearing lifejackets (on board or towed):

DAMAGE TO YOUR OTHER PROPERTY (NOT BOAT)
Briefly summarize any damage to your other property (not boat):

OTHER BOATS INVOLVED IN ACCIDENT
# of other boats involved?
U.S. Dept. of Homeland Security

U.S. Coast Guard CG-3865 (Rev 03-08)

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For each question below, please provide answers IF APPLICABLE AND IF KNOWN, otherwise leave blank.
YOUR BOAT
BOAT IDENTIFICATION
Your boat name:

Manufacturer:

Model name:

Model year:

Registration #:

Documentation #:

Hull Identification # (HIN):
SIZE ESTIMATES
Length:
ft.

Rented:

Depth from transom (stern) to
keel (bottommost point):

HULL MATERIAL
Type of hull material (select one):
| Fiberglass
| Wood
| Aluminum
| Steel
BOAT TYPE
Boat type (select one):
| Cabin motorboat
| Open motorboat
| Auxiliary sail
| Pontoon boat
ENGINE
# engines:
Manufacturer:

| Inflatable
| Houseboat
| Sail (only)
| Kayak

| Yes

| No

Beam width at widest point:
ft.

| Rubber/vinyl/canvas
| Plastic

| Other (describe):

| Canoe
| Personal watercraft (PWC)
| Rowboat
(e.g., Wave Runner™,
| Air boat
Jet Ski™, Sea-Doo™)
| Other (describe):

Engine type and horsepower (select one):
| Outboard | Sterndrive (I/O)
Total horsepower:

ft.

in.

| Inboard

Available propulsion (select all that apply):
… Propeller
… Air thrust
… Sail
… Other (describe):
… Manual
… Water jet

| None

hp

Fuel type (select all that apply):
… Gasoline … Electric
… Diesel

SAFETY MEASURES
Organizations that have conducted a vessel safety check (VSC) on board your boat within the past year (including carriage of
safety equipment, e.g., lifejackets, anchor and line, fire extinguishers): … Federal Agency (Name):
… US Coast Guard Auxiliary: VSC Decal? | Yes

… State Agency (Name):

… US Power Squadrons:

… Other Agency (Name):

# Life jackets on board:

| No
VSC Decal? | Yes | No
# Fire extinguishers on board:

Type of fire extinguishers (e.g., ABC):

# Fire extinguishers used:

Amount of fire extinguisher used:

ACCIDENT DETAILS - EXTERNAL CONDITIONS
WEATHER
Overall weather was (select one):
| Clear
| Raining
| Cloudy
| Snowing
| Foggy
| Hazy
| Other (describe):

It was
Visibility was
(select one):
(select one):
| Day
| Good
| Night
| Fair
| Poor
Approximate air temperature:

WATER
Overall water conditions (select one):
| Up to 6 in. waves (calm)
| Over 6 in., up to 2 ft. waves (choppy)
| Over 2 ft., up to 6 ft waves (rough)
| Over 6 ft. waves (very rough)
U.S. Dept. of Homeland Security

Wind was (select one):
| 0 mph (none)
| Over 0, up to 12 mph (light)
| Over 12, up to 25 mph (moderate )
| Over 25, up to 55 mph (strong)
| Over 55 mph (stormy)
o

F

Other water conditions:
o
Approximate water temperature:
F
Strong current?
Hazardous waters?(e.g., rapid tidal flow, currents)
Congested waters?
U.S. Coast Guard CG-3865 (Rev 03-08)

| Yes
| Yes
| Yes

| No
| No
| No

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For each question below, please provide answers IF APPLICABLE AND IF KNOWN, otherwise leave blank.
ACCIDENT DETAILS - ACTIVITIES AND OPERATIONS ON YOUR BOAT
OPERATOR/PASSENGER ACTIVITIES
Operator/passenger activities on your boat at time of accident :
Activities were (select one):
Operator/passenger activities (select all that apply):
… Fishing
… Tubing
… Starting engine
| Recreational

… Making repairs
| Commercial
Hunting
Water Skiing
… White water activity (e.g., rafting)
… Relaxing
BOAT OPERATIONS
Your boat operations at time of accident (select all that apply):
… Cruising (underway under power)
… Drifting
… Racing
… Changing direction
… At anchor
… Rowing/paddling
… Changing speed
… Being towed
… Tied to dock/mooring
… Sailing
… Other (list):

… Other (list):

… Towing another vessel
… Launching
… Docking/undocking

ACCIDENT DETAILS - CONTRIBUTING FACTORS ON YOUR BOAT
CONTRIBUTING FACTORS
Indicate factors on your boat which may have contributed to this accident (select all that apply):
… Alcohol use
… Operator inattention
… Hazardous waters
… Restricted vision (e.g., fog)
… Drug use
… Operator inexperience
… Heavy weather
… Missing/inadequate
… Excessive speed
… Language barrier
… Hull failure
aids to navigation (e.g., buoy,
… Improper anchoring
… Navigation rules violation … Ignition of fuel or vapor
daymarker)
… Improper loading
… Failure to vent
… Starting in gear
… Inadequate on-board
… Overloading
… Dam/lock
… Sharp turn
navigation lights
… People on gunwale, bow
… Improper lookout
… Force of wake/wave
… Other (describe):
or transom

ACCIDENT DETAILS - YOUR BOAT
MACHINERY/EQUIPMENT FAILURE
Failure of the following machinery/equipment on your boat contributed to this accident (select all that apply):
… Engine
… Sail/mast
… Steering
… Radio
… Fire extinguisher
… Electrical system
… Onboard lights … Throttle
… Auxiliary equipment … Ventilation
… Fuel system
… Seats
… Shift
… Sound equipment (e.g., horn, whistle)
… Onboard navigation aids (e.g., GPS, Loran)

… Other (list):

ACCIDENT DETAILS - EVENTS ON YOUR BOAT
ACCIDENT EVENTS
Types of events occurring to/on your boat during accident (select all that apply):
… Collision with recreational boat
… Flooding/swamping
… Person fell overboard
… Collision with commercial boat (e.g., tug, barge)
… Fire/explosion - fuel
… Person fell on/within boat
… Collision with fixed object (e.g., dock, bridge)
… Fire/explosion - non-fuel
… Sudden medical condition
… Collision with submerged object (e.g., stump, cable) … Carbon monoxide exposure … Person struck by boat
… Collision with floating object (e.g., log, buoy)
… Mishap of skier, tuber,
… Person struck by
… Capsizing
wakeboarder, etc.
propeller or propulsion unit
… Grounding
… Person left boat voluntarily … Person electrocuted
… Sinking
… Person ejected from boat (caused by collision or manuever)
… Other (describe):
U.S. Dept. of Homeland Security

U.S. Coast Guard CG-3865 (Rev 03-08)

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For each question below, please provide answers IF APPLICABLE AND IF KNOWN, otherwise leave blank.
ACCIDENT DETAILS - YOUR BOAT INJURED PEOPLE RECEIVING OR IN NEED OF TREATMENT BEYOND FIRST AID
Report only injured people on, struck by, or being towed by your boat , receiving or in need of treatment beyond first aid.
Do not report injured people on, struck by, or being towed by another boat or no boat (e.g., swimmers, people on a dock).
If more than one injured person to report, attach additional copies of this page. If none , SKIP INJURED PEOPLE section.
INJURED PERSON
First:

MI:

Last:

Street:

City:
Phone:

State:
-

-

-

Age:

INJURY DETAILS
Injury caused when person (select all that apply):
… Struck the:
(e.g., boat, water)
… Was struck by a:
(e.g., boat, propeller)
… Was exposed to carbon monoxide poisoning
… Received an electric shock
… Other (describe):
Person was wearing lifejacket?
Person received treatment beyond first aid?
Person was admitted to a hospital?

Zip:

| Yes
| Yes
| Yes

| No
| No
| No

Nature of most serious injury (select one):

| Scrape/bruise
| Cut
| Sprain/strain
| Concussion/brain injury
| Spinal cord injury
| Broken/fractured bone

| Dislocation
| Internal organ injury
| Amputation
| Burn
| Other (describe):

Body part of most serious injury (e.g., head, hip, knee):

ACCIDENT DETAILS - YOUR BOAT - DEATHS/DISAPPEARANCES
Only report deaths/disappearances of people on, struck by, or being towed by your boat.
If more than one death/disappearance to report, attach additional copies of this page.
If none , SKIP DEATHS/DISAPPEARANCES section.
PERSON WHO DIED/DISAPPEARED
First:

MI:

Last:

Street:

City:
Phone:

State:
-

-

Zip:

Age:

DETAILS OF DEATH/DISAPPEARANCE
Injury caused when person (select all that apply):
… Struck the:
(e.g., boat, water)
… Was struck by a:
(e.g., boat, propeller)
… Was exposed to carbon monoxide poisoning
… Received an electric shock
… Other (describe):

Nature of death/disappearance (select one):
| Death - by drowning
| Death - other likely cause (describe):

| Disappeared and not yet recovered
Person was wearing lifejacket?

U.S. Dept. of Homeland Security

-

U.S. Coast Guard CG-3865 (Rev 03-08)

| Yes

| No

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For each question below, please provide answers IF APPLICABLE AND IF KNOWN, otherwise leave blank.
ACCIDENT DETAILS - YOUR BOAT OPERATOR
OPERATOR INSTRUCTION
Boating safety instruction completed (select all that apply):
… None
… State course
… USCG Auxiliary course
… US Power Squadrons course
… Internet (name of sponsoring organization):

OPERATOR SAFETY MEASURES
On board, prior to accident, was operator wearing:
A lifejacket?
| Yes
| No
An engine cut-off switch (Lanyard or wireless device)
if equipped?
| Yes
| No
On board, prior to accident, was operator using:
Alcohol?
| Yes
| No

… Other (describe):

Drugs?

| Yes
OPERATOR EXPERIENCE
Experience operating this type of boat (select one):

| 0 to 10 hours
| Over 10, up to 100 hours

| No

Operator arrested for Boating Under the Influence?

| Yes

| Over 100, up to 500 hours
| Over 500 hours

| No

Weather reports consulted prior to accident?

| Yes

| No

ACCIDENT DETAILS - OTHER KEY PEOPLE
Only report other key people not already documented as injured, died, disappeared or operator/owner of your boat.
If more than two other key people to report, attach additional copies of this page.
NAME/ADDRESS
This other key person was a(n) (select all that apply):
… Other boat operator … Other boat owner

… Owner of other damaged property

First:

MI:

… Passenger on your boat

… Witness

Last:

Street:

City:

State:

Other boat name (if any):
Other boat registration # (if any):

Zip:
Phone:

-

-

NAME/ADDRESS
This other key person was a(n) (select all that apply):
… Other boat operator … Other boat owner
First:

… Owner of other damaged property
MI:

… Passenger on your boat

… Witness

Last:

Street:

City:
Other boat name (if any):
Other boat registration # (if any):
U.S. Dept. of Homeland Security

State:

Zip:
Phone:

U.S. Coast Guard CG-3865 (Rev 03-08)

-

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For each question below, please provide answers IF APPLICABLE AND IF KNOWN, otherwise leave blank.
YOUR BOAT OPERATOR
NAME/ADDRESS
First:

MI:

Last:

Street:

City:

State:

Zip:

-

AGE/GENDER/PHONE
Age:

Gender:

| Male | Female

Phone:

-

-

YOUR BOAT OWNER
If same as your boat operator SKIP rest of YOUR BOAT OWNER section.
NAME/ADDRESS/PHONE
First:

MI:

Last:

Street:

City:
Phone:

State:
-

Zip:

-

-

PERSON SUBMITTING THIS REPORT
If same as your boat operator OR owner , SKIP rest of PERSON SUBMITTING THIS REPORT section.
NAME/ADDRESS/PHONE/ROLE
First:

MI:

Last:

Street:

City:
Phone:

State:
-

Zip:

-

-

I was a(n) (select one):
| Other person on board this boat
| Accident witness not on board this boat
| Other (describe):

SIGNATURE OF PERSON SUBMITTING THIS REPORT
Your signature:

Date:

mm/dd/yy

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-5422), U.S. Coast Guard, Washington, DC 20593-0001 or Office of Management and Budget, Paperwork Reduction Project (1625-0003), Washington, DC 20503.

U.S. Dept. of Homeland Security

U.S. Coast Guard CG-3865 (Rev 03-08)

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