Safety checklist

9HVVHO6DIHW\&KHFNOLVW
All highlighted equipment and safety topics must be checked off before you leave port.
Do not deploy if any are not verified or current.
9HVVHO QDPH:
USCG/State registration#:

Life Rafts

'eFaO 9eUiÀFatiRQ

†,QÀDWDEOHV†%XR\DQWDSSDUDWXV† None
7oWDO FDSDFLW\

† N$

7oWDO  SeoSOe on EoDUG

/LIe UDIWV DEOe Wo ÀoDW IUee" † Yes

CoPSlete tKe aEoYe stLFNeU as Lt
aSSeaUs on tKe Yessel %e sXUe tKe IolloZLnJ ¿elGs aUe FKeFNeG
† 'oFXPenteG

† No

6eUYLFe sWLFNeU e[SLUDWLon GDWe

,s tKe GeFal YalLG"

† /oFatLons

+\GUosWDWLF UeOeDse e[SLUDWLon

† Yes † No

† ([SLUatLon \eaU

/LIe UDIW eTXLSPenW"
† 3$

† 3%

Immersion Suits
2n EoaUG"

† ([SLUatLon PontK
















† 62/$6 $ † 62/$6 % † Coastal

† 2Fean 6eUYLFe

† Yes † No

Flares
Required (unless inside 3 miles); 6 handheld, 3 Parachute, 3 Smoke

† N$

2ne IoU eaFK SeUson" † Yes † No

/oFatLons

/oFatLon

+anGKelG KoZ Pan\

([S Gate

3)' IoU eaFK SeUson † Yes † No /oFatLon

3aUaFKXte KoZ Pan\

([S Gate

6PoNe KoZ Pan\

([S Gate

0eteoU KoZ Pan\

([S Gate

Fire ([tinJuisKers
Present:

† Yes

† No

Serviceable?

† Yes

† No

7\Se I9 7KroZaEle
† 5LnJ

How many?

/oFatLon

† CXsKLon † /LIeslLnJ

(asLl\ aFFessLEle"

† Yes † No

NXPEeU

/oFatLons

2tKeU sLJnalLnJ GeYLFes

EPIRBS
3Uesent" † Yes † No † N$ ,n ÀoatIUee loFatLon" † Yes † No 5eJLsteUeG to tKLs Yessel" † Yes † No 6LJnal testeG" † Yes † No
'eFal¶s alSKanXPeULF FoGe PatFKes (3,5% FoGe"

† Yes † No /oFatLons

%atteU\ e[S Gate

+\GUostatLF Uelease e[S Gate

N2$$ UeJLstUatLon stLFNeU

([S Gate

$GGitional &KeFNs
)LUst aLGe PateULals SUesent" † Yes

† No /oFatLon

:Ko EesLGes \oX Ls C35 CeUtL¿eG" NaPe SosLtLon
:oUNLnJ UaGLos KoZ Pan\"

7\Se

:ateUtLJKt GooUsKatFKes ZoUNLnJ SUoSeUl\" † Yes

† No

,s tKeUe an anFKoU SUesent"

† Yes

† No

'LG \oX see tKe ELlJe SXPSs"

† Yes

† No

,s tKeUe a 6tatLon %Lll SosteG"

† Yes

† No

+atFKesSassaJeZa\s XnoEstUXFteG"

† Yes

† No

:as a ZKeel ZatFK aUUanJeG"

† Yes

† No

'LG \oX KeaU tKe JeneUalKLJK ZateU alaUPs" † Yes

† No

CKaUts anG FoPSass SUesent"

† Yes

† No

,s tKeUe aGeTXate Peans oI esFaSe"

† No

:eUe \oX JLYen ePeUJenF\ GLUeFtLons"

† Yes

† No

† Yes

:Kat ZeUe tKe ePeUJenF\ LnstUXFtLons"
2EseUYeU sLJnatXUe
Date:

3ULnt
* Expires the last day of the month displayed. ** Hydrostatic releases are valid for two years from installation date.

20% ContUol No  e[S 



&omSleteG 9essel Safet\ &KeFNlist
After completing the checklist, sign the form, print your name and date it. Mail, fax or email a copy of the checklist and all
associated notes to your provider. If you have any safety questions or concerns, please contact the following coordinators:

-oKn /a)argXe C$ CoorGinator
 ) 6tUeet 
(XUeNa C$ 
2I¿Fe: 
Cell: 
(PaLl: -oKn/a)aUJXe#noaaJoY

SFott /eaFK :$/25 CoorGinator
+at¿elG 0aULne 6FLenFe CenteU
 6( 268 DU
NeZSoUt 25 
)a[: 
2I¿Fe: 
Cell: 
(PaLl: 6Fott/eaFK#noaaJoY

Notes