Form CG-4917 (10/15) CG-4917 (10/15) Defect/Noncompliance Report

DEPARTMENT OF HOMELAND SECURITY

OMB No: 1625-0010
Exp. Date: 04/30/2019

U.S. Coast Guard
DEFECT/NONCOMPLIANCE REPORT

Mail to: U.S. Department of Homeland Security, Commandant (CG-BSX-23), U.S. Coast Guard Stop 7501
2703 Martin Luther King Jr Ave SE, Washington, DC 20593-7501
An agency may not conduct or sponsor, and a person is not required to respond to a collection of information
unless it 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: U.S. Department of Homeland Security, Commandant (CG-BSX-23),
U.S. Coast Guard Stop 7501, 2703 Martin Luther King Jr Ave SE, Washington DC 20593-7501 or Office of
Management and Budget, Paperwork Reduction Project (1625-0010) Washington, DC 20503.

CAMPAIGN NUMBER

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 WHCH PRODUCTS RECALLED WILL BE ORRECTED (use additional space on Page 2 if necessary)
a. Who will perform corrections?

b. Where will corrections be performed?

c. When will corrections be performed?

d. How will corrections be performed?

CG-4917 (10/15)

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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 THISREPORT, WHEN
WILL THE INFORMATION BE AVAILABLE?

Privacy Act Statement
a. Authority: 

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. Purpose: 

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. Routine Uses:  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. Disclosure: 

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 OF PREPARER

TITLE

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:
CG-4917 (10/15)

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