Boating Accident Report Form

DEPARTMENT OF HOMELAND SECURITY FORM APPROVED OMB NO. 1625-0003 BOATING ACCIDENT REPORT CASE NUMBER U.S. COAST GUARD CG-3865 THE OPERATOR OF A VESSEL THAT IS BEING USED FOR RECREATIONAL PURPOSES IS REQUIRED TO FILE THIS REPORT IMMEDIATELY TO THE REPORTING AUTHORITY IN THE STATE WHERE THE ACCIDENT OCCURRED WHENEVER AN ACCIDENT RESULTS IN LOSS OF LIFE OR DISAPPEARANCE OF A PERSON AN INJURY WHICH REQUIRES MEDICAL TREATMENT BEYOND FIRST AID PROPERTY DAMAGE OF 2 000 OR MORE OR COMPLETE LOSS OF THE VESSEL. STATE AUTHORITIES MAY REQUIRE REPORTS OF PROPERTY DAMAGE LESS THAN 2 000. THE OWNER OF THE VESSEL SHALL FILE THE REPORT IF THE OPERATOR CANNOT. COMPLETE ALL BLOCKS INDICATE THOSE NOT APPLICABLE BY NA ACCIDENT DATA NUMBER OF PERSONS DECEASED NUMBER INJURED BEYOND F IRST AID NUMBER OF VESSELS INVOLVED TOTAL PROPERTY DAMAGE AMOUNT DATE OF ACCIDENT TIME LOCATION NAME STATE AM NUMBER DISAPPEARED WAS VESSEL A TOTAL LOSS DD MM SS WGS84 LATITUDE PM YES NO COUNTY NAME OF BODY OF WATER NUMBER OF MILES OFF-SHORE ATLANTIC OCEAN LONGITUDE NEAREST CITY OR TOWN REPORT STATUS GULF OF MEXICO PACIFIC OCEAN STATE REPORTABLE USCG NON-REPORTABLE WIND TEMPERATURE CALM WAVES LESS THAN 6 USCG REPORTABLE COMMERCIAL RECREATIONAL WATER CONDITIONS WEATHER CHECK ALL APPLICABLE ALCOHOL INVOLVED VISIBILITY AIR NONE RAIN CHOPPY WAVES 6 TO 2 DAY SNOW ROUGH WAVES 2 TO 6 MODERATE 13 - 24 MPH FOG HAZY VERY ROUGH GREATER THAN 6 STRONG 25 - 54 MPH STRONG / SWIFT CURRENT F LIGHT 0 - 12 MPH CLOUDY CLEAR STORM 55 MPH AND OVER NIGHT GOOD POOR OPERATOR / OWNER INFORMATION OPERATOR NAME LAST FIRST STREET ADDRESS TELEPHONE NUMBER MIDDLE INITIAL CITY ZIP DATE OF BIRTH MO/DAY/YR OPERATOR EXPERIENCE WITH THIS VESSEL AGE IN YEARS OPERATOR INSTRUCTION IN BOATING SAFETY MALE UNDER 10 HOURS OVER 500 HOURS STATE COURSE INTERNET COURSE 10 TO 100 HOURS FEMALE OTHER USCG AUXILIARY SPECIFY OTHER SPECIFY US POWER SQUADRONS OWNER NAME VESSEL A NUMBER DECEASED FOR THIS VESSEL OPERATOR DECEASED THIS VESSEL AMOUNT OF DAMAGE FOR THIS VESSEL DESCRIBE VESSEL DAMAGE DESCRIBE OTHER PROPERTY DAMAGE VESSEL REGISTRATION NUMBER HULL IDENTIFICATION NUMBER HIN VESSEL MODEL VESSEL DOCUMENTATION NUMBER YEAR BUILT NAME OF VESSEL MANUFACTURER VESSEL SAFETY CHECK VSC NU MBER RENTED VESSEL OPERATOR LIVED AT VESSEL OWNER S RESIDENCE VESSEL OWNER WAS OCCUPANT VESSEL LENGTH IN FEET AND INCHES OPERATOR BUI ARREST NOT PRESENT COAST GUARD USCG APPROVED PERSONAL FLOTATION DEVICES PFDS VESSEL EQUIPPED WITH USCG APPROVED PFDS WEARING USCG PFD ON BOARD USCG APPROVED PFDS ACCESSIBLE USED SAFETY LANYARD USED PAGE 1 OF 6 FIRE EXTINGUISHERS TYPE OF VESSEL AIR BOAT VESSEL HULL MATERIAL OPEN MOTORBOAT AUXILIARY SAIL CABIN MOTORBOAT PROPELLER WATER JET MANUAL RIGID HULL INFLATABLE NUMBER OF ENGINES KEVLAR ROWBOAT PLASTIC SAIL ENGINE MAKE AIR THRUST ROYALEX POLYETHYLENE SAIL ONLY FUEL GASOLINE DIESEL ELECTRIC WOOD JET BOAT STERNDRIVE - INBOARD I/O RUBBER/VINYL/CANVAS PONTOON BOAT KAYAK OUTBOARD ALUMINUM WATERCRAFT PWC HOUSEBOAT PROPULSION ENGINE FIBERGLASS PERSONAL CANOE CONTINUED TOTAL HORSEPOWER FOR PRIMARY ENGINE S STEEL ENGINE SERIAL NUMBER S ACCIDENT EVENTS AND CONTRIBUTING FACTORS ACTIVITY AT TIME OF ACCIDENT AT ANCHOR COMMERCIAL ACTIVITY CAPSIZING GROUNDING BEING TOWED FISHING CARBON MONOXIDE EXPOSURE PERSON LEAVES A VESSEL CHANGING DIRECTION FUELING COLLISION WITH FIXED OBJECT CHANGING SPEED HUNTING CRUISING MAKING REPAIRS OBJECT PERSON EJECTED FROM A DRIFTING ELECTROCUTION RACING STARTING ENGINE LAUNCHING SWIMMING ROWING/PADDLING SCUBA DIVING / SNORKELING SAILING FISHING TOURNAMENT TIED TO DOCK/MOORING TUBING TOWING ANOTHER VESSEL WATER SKIING WHITEWATER BOATING DID THE ACCIDENT RESULT IN A HIT AND RUN ESTIMATED SPEED AT TIME OF ACCIDENT SKIER MISHAP STRUCK BY VESSEL FALL WITHIN A VESSEL DOCKING/UNDOCKING BOATING CITATIONS ISSUED SINKING STRUCK BY PROPELLER OR FALL ON A VESSEL STRUCK SUBMERGED OB JECT FALLS OVERBOARD FIRE OR EXPLOSION OTHER FLOODING/SWAMPING OPERATOR REPORT STATUS NUMBER OF PEOPLE ON BOARD COMPLETE NOT MOVING UNDER 10 MPH 10-20 MPH 21-40 MPH OVER 40 MPH IDLING PLOWING ACCELERATING PLANING ON PLANE CONTRIBUTING FACTORS PRIMARY SECONDARY A ND TERTIARY USING 1 2 3 SPECIFY EQUIPMENT FAILURE ALCOHOL USE LACK OF / IMPROPER BOAT LIGHTS AUXILIARY EQUIPMENT FAILURE CARELESS/RECKLESS COMMUNICATION EQUIPMENT FAILURE OVERLOADING PASSENGER / SKIER BEHAVIOR SAIL DISMASTING RESTRICTED VISION SEAT BROKE LOOSE RULES OF THE ROAD VIOLATION SOUND PRODUC ING EQUIPMENT FAILURE SHARP TURN VISUAL DISTRESS SIGNALS FAILED CONGESTED WATERS DAM / LOCK DRUG USE EQUIPMENT FAILURE EXCESSIVE SPEED FAILURE TO VENT STANDING / SITTING ON GUNWALE BOWS AND TRANSOM HAZARDOUS WATERS STARTING IN GEAR VESSEL HULL FAILURE WAKE IGNITION OF SPILLED FUEL OR VAPOR WEATHER HEAVY MACHINERY FAILURE NO PROPER LOOKOUT OFF-THROTTLE STEERING IMPROPER ANCHORING NAVIGATION AID MISSING IMPROPER LOADING SPECIFY MACHINERY FAILURE ELECTRIC SYSTEM FAILURE ENGINE FAILURE FUEL SYSTEM FAILURE SHIFT FAILURE STEERING SYSTEM FAILURE THROTTLE FAILURE VENTILATION SYSTEM FAILURE ACCIDENT DESCRIPTORS BOAT FOUND CAPSIZED BOAT STRUCK BY LIGHTNING VICTIM STRUCK BY BOOM PARASAILING ACCIDENT RUNAWAY BOAT ESTIMATED NUMBER OF DAYS VESSEL USED THIS YEAR BOAT FOUND UPRIGHT DRIFTING OCCUPANTS DISAPPEARED VICTIM ENTANGLED IN LINES TYPICAL NUMBER OF HOURS VESSEL USED EACH DAY THIS YEAR OTHER PEOPLE ON BOARD THIS VESSEL IF MORE THAN 2 PEOPLE ATTACH ADDITIONAL FORMS NAME WAS PFD WORN PFD WORN PRIOR TO ACCIDENT PFD WORN AS A RESULT OF ACCIDENT WAS PFD WORN INFLATABLE IF TWO 2 OR MORE VESSELS WERE INVOLVED DID THE OPERATOR S OF THE VESSEL S FILE A REPORT VESSEL B SECOND VESSEL EACH OPERATOR IS REQUIRED TO FILE A SEPARATE REPORT PROPERTY DAMAGE FOR THIS VESSEL S AND CONTENTS DESCRIBE PROPERTY DAMAGE WITNESSES NOT ON THIS VESSEL IF MORE THAN 2 LIST ON SEPARATE SHEET PHONE NO.