Form CG-4917 Defect/NonCompliance Report

U.S. DEPARTMENT OF
HOMELAND SECURITY
U.S. COAST GUARD
CG-4917 (Rev. 9-05)

DEFECT/NONCOMPLIANCE REPORT

OMB NO. 1625-0010

Mail to: Commandant (G-OPB-3), USCG, Washington, DC 20593-0001

An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it CAMPAIGN NUMBER
displays a valid OMB control number. The Coast Guard estimates that the average burden for this report form is one
hour. You may submit any comments concerning the accuracy of this burden estimate or any suggestions for reducing
the burden to: Commandant (G-OPB-3), U.S. Coast Guard, Washington, DC 20593-0001 or Office of Management
and Budget, Paperwork Reduction Project (1625-0010), Washington, DC 20503.

1. NAME AND ADDRESS OF COMPANY CONDUCTING DEFECT NOTIFICATION CAMPAIGN (include ZIPCODE)

2. NAME AND PHONE NUMBER OF PERSON TO CONTACT
3. IF DEFECTIVE COMPONENT, MANUFACTURER NAME AND ADDRESS:

4a. IDENTIFICATION OF BOATS POTENTIALLY INVOLVED (use other means or additional space on Page 2 if necessary):
MODEL

HIN

to

MODEL

HIN

to

MODEL

HIN

to

MODEL

HIN

to

4b. IF PRODUCTS INVOLVED ARE NOT BOATS (use other means or additional space on Page 2 if necessary):
MODEL

SERIAL NOS.

to

YEAR

MODEL

SERIAL NOS.

to

YEAR

MODEL

SERIAL NOS.

to

YEAR

5. DESCRIPTION OF DEFECT OR NONCOMPLIANCE:

6. DEGREE OF DANGER TO THE PUBLIC WITH CONTINUED USE OF THE PRODUCT WITHOUT REPAIR OR CORRECTION:

7. MANNER IN WHICH PRODUCTS RECALLED WILL BE CORRECTED (use additional space on Page 2 if necessary):

a. Who will perform corrections?

b. Where will corrections be performed?

PREVIOUS EDITIONS ARE OBSOLETE

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c. When will corrections be performed?

d. How will corrections be performed?

8. ACTIONS TAKEN TO DATE TO CORRECT THIS DEFECT OR NONCOMPLIANCE:

9. LOCATION OF UNITS:

10. CURRENT STATUS OF CAMPAIGN:

a. Number of units sold to consumers:

a. Number of units which might contain the problem:

b. Number of units at the factory:

b. Number of first purchasers notified about the problem:

c. Number of units shipped to dealers:

c. Number or dealers or distributors notified about the problem:

d. Locations of other units:

d. Number of units corrected or repaired:
e. Number of units inspected which did not have problem:
f. Number of owners who refused the offer to repair or correct
(an owner who refuses must do so in writing)

11. IF ANY OF THE INFORMATION REQUESTED IN 9. AND 10. ABOVE IS NOT AVAILABLE WHEN SUBMITTING THIS
REPORT, WHEN WILL THE INFORMATION BE AVAILABLE?

THIS FORM IS AUTHORIZED BY 46 U.S.C. CHAPTER 43 AND 33 CFR 179 FOR THE COLLECTION OF INFORMATION
CONCERNING THE PRODUCTS INVOLVED IN THIS DEFECT NOTIFICATION AND RECALL CAMPAIGN. THE
INFORMATION PROVIDED ON THIS FORM WILL BECOME A PART OF THE OFFICIAL U.S.COAST GUARD FILE
COVERING THIS CAMPAIGN AND WILL BE USED IN EVALUATING THE DILIGENCE WITH WHICH YOUR
COMPANY CONDUCTS THIS CAMPAIGN. FAILURE TO SUBMIT THIS REPORT FORM WITHIN SPECIFIED TIME
CONSTRAINTS CAN RESULT IN A CIVIL PENALTY OF $1000.
SIGNATURE AND TITLE OF PREPARER:

DATE:

SPACE FOR ADDITIONAL INFORMATION:
List the model name, length, model year and type of propulsion for boats for which affected Hull Identification Number (HIN) sequences
in item 4a. are not available

THE COAST GUARD MUST
RECEIVE THIS REPORT ON
OR BEFORE:

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