Form CG-4917 Defect/NonCompliance Report

DEPARTMENT OF HOMELAND SECURITY

U. S. Coast Guard
DEFECT/NONCOMPLIANCE REPORT

Mail to: Commandant (CG-54223), USCG, 2100 Second Street, SW STOP 7581, Washington, DC 20593-7581

OMB NO. 1625-0010
Exp. Date 03/31/2012

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 (CG-54223), U.S. Coast Guard, 2100 Second Street, SW STOP 7581, Washington, DC
20593-7581 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?

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CG-4917 (11/11)

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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?
a. $XWKRULW\ 5 U.S.C. 301; 14 U.S.C. 93; the Federal Records Act; 46 U.S.C. 4310; and 33 C.F.R. 179.
b. 3XUSRVH The Coast Guard will use this information to identify boats (as that term is defined in 33 C.F.R. 179.03), inboard
engines, outboard motors, stern drive units and inflatable personal floatation devices approved under 46 C.F.R. 160.076 being
recalled for repair and replacement of defects or noncompliance with a regulation prescribed under 46 U.S.C. 4302, to
determine the severity of the defect(s) or noncompliance, the location of the defective product(s), how and by whom the
defect(s) or noncompliance will be corrected and the degree of danger to the public should the items continue to be used without correction of the defect(s) or noncompliance.
c. 5RXWLQH8VHV In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these
records or information contained therein may specifically be disclosed outside the Department of Homeland Security as a
routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: in accordance with the routine uses described in DHS/USCG-013
Marine Information for Safety and Law Enforcement (MISLE) System of Records.
d. 'LVFORVXUH Completion/furnishing of this form is MANDATORY. Failure to provide the information requested within 30
days after the manufacturer discovers or acquires information of the defect or failure to comply with applicable regulation(s)
may result in a civil penalty of up to $1100.

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) se quences
in item 4a. are not available

THE COAST GUARD MUST
RECEIVE THIS REPORT ON
OR BEFORE:

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