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pdfDEPARTMENT OF HOMELAND SECURITY
OMB No: 1625-0001
U.S. Coast Guard
Exp. Date: 03/31/2019
REPORT OF MANDATORY CHEMICAL TESTING FOLLOWING A SERIOUS MARINE INCIDENT
INVOLVING VESSELS IN COMMERCIAL SERVICE
Note: This form shall be used to report data on persons directly involved in a serious marine incident involving a vessel in commercial service and the
mandatory chemical drug and alcohol testing.
Section I - Reporting Vessel Information - Casualty Date/Time
1. Vessel Name
2. Vessel Official Number or IMO Number
3. Date/Time (local) of Occurrence
Section II - Reason for Submitting this Report (Check all that apply)
4. The above vessel is in commercial service and was involved in a Serious Marine Incident that resulted in (46 CFR 4.03-2):
One or more deaths
An injury to a crewmember, passenger, or other person that requires professional medical treatment beyond first aid, and, in the case of a person
employed on board a vessel in commercial service, which renders the individual unfit to perform routine vessel duties
Damage to property in excess of $200,000
Actual or constructive total loss of any vessel subject to inspection under 46 USC 3301
Actual or constructive total loss of any self-propelled vessel, not subject to inspection under 46 USC 3301, of 100 gross tons or more
A discharge of oil of 10,000 gallons or more into the navigable waters of the United States, as defined in 33 USC 1321
A discharge of a reportable quantity of a hazardous substance into the navigable waters of the United States
A release of a reportable quantity of a hazardous substance into the environment United States
Section III - Personnel and Testing Information
5. Individuals Directly Involved in Serious Marine Incident 6. Drug and Alcohol Testing
5a. Name (Last, First, Middle)
5b. USCG
Credentialed?
6a. Drug Test Urine Sample
Provided Within 32 Hours?
6b. Alcohol Test Specimen
Provided within 2 Hours?
6c. Type of Alcohol Test
Specimen Provided
6d. Alcohol
Test Results
Yes
No
Yes
No
Refused
Yes
No
Refused
Saliva
Blood
Breath
Yes
No
Yes
No
Refused
Yes
No
Refused
Saliva
Blood
Breath
Yes
No
Yes
No
Refused
Yes
No
Refused
Saliva
Blood
Breath
Yes
No
Yes
No
Refused
Yes
No
Refused
Saliva
Blood
Breath
Yes
No
Yes
No
Refused
Yes
No
Refused
Saliva
Blood
Breath
Yes
No
Yes
No
Refused
Yes
No
Refused
Saliva
Blood
Breath
Yes
No
Yes
No
Refused
Yes
No
Refused
Saliva
Blood
Breath
Yes
No
Yes
No
Refused
Yes
No
Refused
Saliva
Blood
Breath
Yes
No
Yes
No
Refused
Yes
No
Refused
Saliva
Blood
Breath
Yes
No
Yes
No
Refused
Yes
No
Refused
Saliva
Blood
Breath
7. Explanation of why test samples were not collected within required timeframes or not at all and/or why testing was not conducted (Required for each “No”
checked in columns 6a or 6b)
8. SAMHSA Accredited Laboratory Conducting Chemical Drug Tests
Name:
9. Laboratory or Individual Conducting Alcohol Tests
Name:
Address:
Address:
Telephone:
Telephone:
Email:
Email:
Section IV - Person Making this Report
10. Name (PRINT) (Last, First, Middle)
11. Signature
13. Title
14. Address
15. Telephone No.
16. Email
CG-2692B (04/18)
12. Date
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INSTRUCTIONS FOR COMPLETION OF FORM CG-2692B
Report of Chemical Testing Following a Serious Marine Incident Involving a Commercial Vessel
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 is .5 hours. You may submit any comments concerning the accuracy of this burden estimate or any suggestions for reducing the
burden to: Commandant (CG-INV), 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 (1625-0001), Washington, DC 20503.
WHEN TO USE THIS FORM
1. This form, when submitted in conjunction with a CG-2692 or submitted alone, satisfies the requirement found in the Code of Federal Regulations for written
reports of chemical drug and alcohol testing of individuals engaged or employed on board a commercial vessel who are identified as being directly involved in
serious marine incidents consisting of one or more of the occurrences lists in block 4. Alcohol tests are to be conducted not later than 2 hours (unless there are
safety concerns directly related to the casualty that need to be addressed by the individual(s)) and drug test specimens collected not later than 32 hours after a
serious marine incident.
INDIVIDUAL DIRECTLY INVOLVED IN A SERIOUS MARINE INCIDENT
2. The term "individual Directly Involved in a Serious Marine Incident" means an individual whose order, action, or failure to act is determined to be, or cannot
be ruled out as, a causative factor in the events leading to or causing a serious marine incident.
COMPLETION OF THIS FORM
3. In accordance with 46 CFR Subpart 4.06 this form shall be filled out as completely and accurately as possible. Please type or print clearly. Fill in all blanks
that apply to the kind of accident that has occurred. If a block is not applicable, the abbreviation “NA” should be entered in that space. If the answer is
unknown and cannot be obtained before the report has to be submitted (i.e. within 5 days of the accident), the abbreviation “UNK” should be entered in that
block. If “NONE” is the correct response, enter it in the block.
4. If more than 10 individuals are directly involved in the Serious Marine Incident additional CG-2692Bs should be completed.
5. Once completed, deliver, email, or fax this form with a corresponding CG-2692 within 5 days of the casualty to the Coast Guard Sector, Marine Safety Unit,
or Activity nearest the location of the casualty or, if at sea, nearest the arrival port. http://www.uscg.mil/top/units/
6. Upon receipt of a report of chemical test results. The marine employer shall submit a copy of the test results for each person listed in block 5a of this form to
the Coast Guard Officer in Charge, Marine Inspection where the CG-2692B was submitted in accordance with 46 CFR §4.06-60(d).
7. Block 6d - Alcohol Test Result: When the alcohol test results are available, the alcohol concentration shall be expressed numerically in percent by weight
(i.e. 0.04, 0.10, etc.); otherwise indicate positive for alcohol being present or negative for no alcohol present.
NOTICE: The information collected on this form is routinely available for public inspection. It is needed by the Coast Guard to carry out its responsibility to
investigate marine casualties, to identify hazardous conditions or situations and to conduct statistical analysis. The information is used to determine whether
new or revised safety initiatives are necessary for the protection of life or property in the marine environment.
CG-2692B (04/18)
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| File Type | application/pdf |
| File Title | CG2692B.PDF |
| Subject | Report of Mandatory Chemical Testing Following a Serious Marine Incident Involving Vessels in Commercial Service |
| Author | FYI, Inc. |
| File Modified | 2018-03-12 |
| File Created | 2014-06-16 |