CG-3865 Recreational Boating Accident Report

DEPARTMENT OF HOMELAND SECURITY

U.S. Coast Guard
RECREATIONAL BOATING ACCIDENT REPORT

OMB Control Number: 1625-0003
Expires: 9/30/2014
xx

INSTRUCTIONS: Use "Report required because" section below to determine if a report is required for your accident. If required, please have each vessel
owner or operator involved in the accident submit a report to their state reporting authority. Each boat operator/owner involved in an accident should submit
a separate report. For each question below, please provide answers if applicable and if known; otherwise leave blank.lllllll
Privacy
P A
Act Notice: Authority- 46
U.S.C. 6102 and 33 CFR 173 & 174 authorize the collection of information on boating accidents. Purpose-The Coast Guard uses this information for statistical
purposes, chiefly to inform the public, to measure the Program's efforts, and to regulate issues relating to boating safety. Routine Uses-The Coast Guard
shares this information within the agency, and if state and federal law permit it, to the public.

REPORT SUBMISSION
Report required because (select all that apply):
At least one person in this accident died:

If so, how many? _______

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? _______
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
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

Last Name

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

Phone:
You may submit any comments concerning 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. Questions
relating to the collection of this data should be sent to the Coast
Guard.

For State Agency Use Only

First Name

Last Name

Phone:
Primary Cause of Accident

Phone

ACCIDENT SUMMARY
WHEN
Date:

(mm/dd/yyyy)

ACCIDENT DESCRIPTION: Briefly describe this accident
Time:

am
pm
(select one)

(attach extra pages if necessary)

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):

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

# people being towed (e.g., on tubes, skis):
# people wearing lifejackets (on board or towed):
OTHER BOATS INVOLVED IN ACCIDENT
# of other boats involved:

CG-3865 (1/11)

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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)

Rented:

Yes

No

SIZE ESTIMATES
Length:

ft.

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

ft.

Beam width at widest point:

in.

ft.

HULL MATERIAL
Type of Hull Material (select one)
Fiberglass

Wood

Rubber/vinyl/canvas

Aluminum

Steel

Plastic

Other (describe):

BOAT TYPE
Boat Type (select one)
Cabin motorboat

Inflatable

Canoe

Open motorboat

Houseboat

Rowboat

Auxiliary sail
Pontoon boat

Sail (only)
Kayak

Air boat

Personal watercraft (PWC)
(e.g., Wave Runner TM, Jet
Ski TM, Sea-Doo TM)
Other (describe)

Available Propulsion (select all that apply)
Propeller
Air thrust
Sail

Other (describe):

Manual
Water jet

ENGINE
# Engines
Manufacturer

Engine type and horsepower (select one)
Outboard
Total horsepower:

Sterndrive (I/O)

Fuel type (select all that apply)
Inboard

None

Gasoline

Diesel

Electric

hp

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):
US Coast Guard Auxiliary:

VSC Decal?

Yes

No

US Power Squadrons:

VSC Decal?

Yes

No

Federal Agency (Name)
State Agency (Name)

# Life jackets on board:

Other Agency (Name)

# Fire extinguishers on board:

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

# Fire extinguishers used:

Amount of fire extinguishers used:

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

It was (select one)
Day
Night

Visibility was (select one)
Good
Fair
Poor
ºF

Approximate air temperature:

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)

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)
CG-3865 (1/11)

Other water conditions:
ºF

Approximate water temperature:
Strong current?

Yes

No

Hazardous waters? (e.g., rapid tidal flow, currents)

Yes

No

Congested waters?

Yes

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)
Recreational
Commercial

Operator/Passenger activities (select all that apply)
Fishing
Tubing
Hunting
Water Skiing
White water activity (e.g., rafting)
Relaxing

Starting engine
Making repairs
Other (list):

BOAT OPERATIONS
Your boat operations at time of accident (select all that apply)
Cruising (underway under power)
Changing direction
Changing speed
Sailing

Drifting
At anchor
Being towed
Other (list)

Racing
Rowing/paddling
Docking/undocking

Towing another vessel
Launching
Tied to dock/mooring

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

Improper lookout

Dam/lock

Starting in gear

Drug use

Operator inattention

Force of wake/wave

Sharp turn

Excessive speed

Operator inexperience

Hazardous waters

Restricted vision (e.g., fog)

Improper anchoring

Language barrier

Heavy weather

Mission/inadequate aids to
navigation (e.g., buoy, daymarker)

Improper loading

Navigation rules violation

Ignition of fuel or
vapor

Inadequate on-board navigation
lights

Overloading

Failure to vent

Hull failure

People on gunwale, bow or transom

Other (describe):

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

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, wake
boarder, etc.

Person struck by propeller or propulsion
unit

Capsizing

Person left boat voluntarily

Person electrocuted

Grounding

Person ejected from boat (caused by collision or maneuver)

Sinking

Other (describe)

CG-3865 (1/11)

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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 Name

MI

Last Name

Street
City

State

Zip

Phone

Date of Birth

Age

(mm/dd/yyyy)

INJURY DETAILS
Injury caused when person (select all that apply)

Nature of most serious injury (select one)

Struck the (e.g., boat, water):

Scrape/bruise

Dislocation

Was struck by a (e.g., boat, propeller):

Cut

Internal organ injury

Was exposed to carbon monoxide poisoning

Sprain/strain

Amputation

Received an electric shock

Concussion/brain injury

Burn

Spinal cord injury

Other (describe):

Other (describe):
Person was wearing lifejacket?

Yes

No

Person received treatment beyond first aid?

Yes

No

Person was admitted to a hospital?

Yes

No

Broken/fractured bone
Body part of most serious injury (e.g., head, trunk, leg):

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 Name

MI

Last Name

Street
City

State

Zip

Phone

Date of Birth

Age

(mm/dd/yyyy)

DETAILS OF DEATH/DISAPPEARANCE
Injury caused when person (select all that apply)

Nature of death/disappearance (select one)

Struck the (e.g., boat, water):

Death – by drowning

Was struck by a (e.g., boat,
propeller):

Death – other likely cause (describe)

Was exposed to carbon monoxide poisoning
Received an electric shock
Other (describe):

CG-3865 (1/11)

Disappeared and not yet recovered
Person was wearing lifejacket?

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

OPERATOR SAFETY MEASURES

Boating safety instruction completed (select all that apply)

On board, prior to accident, was operator wearing:

None

A lifejacket?

Yes

No

Yes

No

Alcohol?

Yes

No

Drugs?

Yes

No

Operator arrested for Boating Under the Influence?

Yes

No

Weather reports consulted prior to accident?

Yes

No

An engine cut-off switch (Lanyard or wireless
device) if equipped?
On board, prior to accident, was operator using:

State course
USCG Auxiliary course
US Power Squadrons course
Internet (name of sponsoring organization)
Other (describe)

OPERATOR EXPERIENCE
Experience operating this type of boat (select one)
0 to 10 hours

Over 10, up to 100 hours

Over 100, up to 500 hours

Over 500 hours

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

First Name

Owner of other damaged property
MI

Last Name

State

Zip

Passenger on your boat

Witness

Street
City
Other boat name (if any)

Phone

Other boat registration # (if any)

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

Other boat owner

Owner of other damaged property
MI

Last Name

State

Zip

Passenger on your boat

Witness

Street
City
Other boat name (if any)

CG-3865 (1/11)

Phone

Other boat registration # (if any)

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YOUR BOAT OPERATOR
NAME/ADDRESS
First Name

MI

Last Name

State

Zip

Street
City

AGE/GENDER/PHONE
Date of Birth
(mm/dd/yyyy)

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 Name

MI

Last Name

State

Zip

Street
City

Phone

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 Name

MI

Last Name

State

Zip

Street
City

Phone

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/yyyy)

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 (CG5422), U.S. Coast Guard, Washington, DC 20593-0001 or Office of Management and Budget, Paperwork Reduction
Project (1625-0003), Washington, DC 20503.
CG-3865 (1/11)

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