CG-2692D (03/16) Involved Persons and Witnesses Addendum

DEPARTMENT OF HOMELAND SECURITY

U.S. Coast Guard
INVOLVED PERSONS AND WITNESSES ADDENDUM

OMB No: 1625-0001
Exp. Date: 03/31/2019

Note: This form shall be used to report data on persons involved or witnessing an OCS-related casualty described on form CG-2692.
This form may only be used in addition to form CG-2692, never alone.

Section I - Reporting Vessel/Facility Information - Casualty Date/Time
1. Vessel or Facility Name

2. Date/Time (local) of Occurrence

Section II - Involved Persons and Witnesses Details
3a. Name (Last, First, Middle)

3b. Relationship to Vessel or Facility
Crew ­

3d. Address
3e. Telephone

Passenger
3f. Email address

4a. Name (Last, First, Middle)

Other ­

Crew ­

4f. Email address

5a. Name (Last, First, Middle)

Crew ­

6a. Name (Last, First, Middle)

Other ­

Crew ­

6f. Email address

7a. Name (Last, First, Middle)

Crew ­

7f. Email address

8a. Name (Last, First, Middle)

Crew ­

9a. Name (Last, First, Middle)

Other ­

Crew ­

9f. Email address

10a. Name (Last, First, Middle)

CG-2692D (03/16)

Position:

Passenger
10f. Email address

Other ­

Involved Person
Witness

6c. Status
Involved Person
Witness

7c. Status
Involved Person
Witness

8c. Status
Involved Person
Witness

9c. Status
Involved Person
Witness

Describe:

10b. Relationship to Vessel or Facility
Crew ­

10d. Address
10e. Telephone

Position:

Passenger
Other ­

5c. Status

Describe:

9b. Relationship to Vessel or Facility

9d. Address
9e. Telephone

Position:

Passenger
8f. Email address

Witness

Describe:

8b. Relationship to Vessel or Facility

8d. Address
8e. Telephone

Position:

Passenger
Other ­

Involved Person

Describe:

7b. Relationship to Vessel or Facility

7d. Address
7e. Telephone

Position:

Passenger
Other ­

4c. Status

Describe:

6b. Relationship to Vessel or Facility

6d. Address
6e. Telephone

Position:

Passenger
5f. Email address

Witness

Describe:

5b. Relationship to Vessel or Facility

5d. Address
5e. Telephone

Position:

Passenger
Other ­

Involved Person

Describe:

4b. Relationship to Vessel or Facility

4d. Address
4e. Telephone

Position:

3c. Status

10c. Status
Involved Person
Witness

Describe:

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INSTRUCTIONS FOR COMPLETION OF FORM CG-2692D
INVOLVED PERSONS AND WITNESSES ADDENDUM
Note:

This form shall be used to report data on persons involved or witnessing an OCS-related casualty described on form CG-2692 and may be used to report data on persons
involved or witnessing a marine casualty or commercial diving casualty described on form CG-2692.
This form may only be used in addition to form CG-2692, never alone.

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, satisfies the requirement for written reports of casualties and accidents found in the Code of
Federal Regulations for OCS-related casualties on OCS Facilities or vessels engaged in OCS activities. Specifically, it provides information on one or more
persons who were involved in or witnessed the casualty. This form may only be used in addition to form CG-2692, never alone.
COMPLETION OF THIS FORM
2. In accordance with 46 CFR §4.05-10, 46 CFR §197.486, and 33 CFR §146.35 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.
3. If more than 8 individuals were involved in or witnessed the casualty additional CG2692Ds should be completed.
4. 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/
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-2692D (03/16)

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