CG-2692B Report of Required Chemical Drug and Alcohol Testing Fol

DEPARTMENT OF HOMELAND SECURITY

OMB No. 1625-0001

U.S. Coast Guard
Expires: 01/31/2016
REPORT OF REQUIRED CHEMICAL DRUG AND ALCOHOL TESTING FOLLOWING A
SERIOUS MARINE INCIDENT
(See Instructions on reverse)

SECTION I—VESSEL INFORMATION

1. Name of vessel

5. Vessel Type (Freight, Towing, Fishing, MODU, etc.)

2. Official Number

3. Call Sign

4. Nationality

6. Length

7. Gross Tons

8. Year Built

9. Operating Company

10. Master or Person in Charge

Name:

Name:

Address:

Address:

Telephone Number:

Telephone Number:

SECTION II—INCIDENT INFORMATION

11. Type of Serious Marine Incident (Check Appropriate Box(es). (See Instructions on Reverse)

a.

Death (Append to Form CG-2692)

e.

b.

Injury requiring medical treatment
(Append to Form CG-2692)

Loss of uninspected, self-propelled vessel of over
100 gross tons (Append to Form CG-2692)

f.

Discharge of oil of 10,000 gallons or more into U.S. waters

c.

Property damage in excess of $100,000
(Append to Form CG-2692)

g.

Discharge of a reportable quantity of hazardous
substance into U.S. waters

d.

Loss of inspected vessel (Append to
Form CG-2692)

h.

Release of a reportable quantity of hazardous substance
into U.S. environment

12. Date of Incident

13. Time (local) of Incident

14. Location of Incident (Latitude and Longitude or River and Milepost)

SECTION III—PERSONNEL / TESTING INFORMATION

NO

YES

NO

__________________________
__________________________
__________________________
__________________________
__________________________
17. SAMHSA Accredited Laboratory Conducting Chemical Drug Tests

________
________
18. Laboratory conducting blood alcohol test(s) or individual conducting saliva or
breath alcohol test(s)
Name:

Address:

Address:

Telephone Number:

16d.
Alcohol
Test
Results

________
________
________

Name:

19. Person Making This Report (Please Print)

Breath

YES

Blood

(Check Appropriate Box(es))
USCG
USCG
License
MMD
Neither

16. Drug and Alcohol Testing (See Instructions on reverse)
16a. Drug Test Urine
16b. Alcohol Test
16c. Alcohol Test
Specimen provided
Specimen provided
Specimen Source
within 32 hours?
within 2 hours?
Saliva

15. Personnel Directly Involved In Serious Marine Incident
15a. Name (Last, First, Middle Initial)
15b. Licensing/Certification

Telephone Number:
20. Signature

21. Date

Name:
Address:
Telephone Number:
22. Remarks (See Instructions on Reverse)

CG-2692B (03/13)

Title:

Page 1 of 2

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INSTRUCTIONS FOR COMPLETION OF FORM CG-2692B
REPORT OF REQUIRED CHEMICAL DRUG AND ALCOHOL TESTING
FOLLOWING A SERIOUS MARINE INCIDENT
NOTE: When this form is being submitted along with a REPORT OF MARINE ACCIDENT, INJURY OR DEATH
(Form CG-2692), Blocks 3-10 and Blocks 12-14 on Form CG-2692B need not be completed.


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7KH&RDVW*XDUGHVWLPDWHVWKDWWKHDYHUDJHEXUGHQIRUWKLVUHSRUWLVKRXUVFile Typeapplication/pdfFile TitleCG2692B.PDFSubjectReport of Required Chemical Drug and Alcohol Testing Following a Serious Marine IncidentAuthorFYI, Inc.File Modified2013-03-28File Created2003-08-27