2260 DENALI
Appendix C:
Appendix C:
Appendix C:
Appendix C:
Appendix C:
C-1
BOATING ACCIDENT REPORT
FORM APPROVED
OMB NO.211-0010
DEPARTMENT OF
TRANSPORTATION
U.S. COAST GUARD
C.G. 1865 (REV. 1/88)
The operator/owner of a vessel used for recreational purposes is required to file a report in writing whenever an accident results in: loss of life or disappearance
from a vessel, or an injury which requires medical treatment beyond first aid: or property damage in excess of $200 or complete loss of the vessel. Reports
in death and injury cases must be submitted within 48 hours. Reports in other cases must be submitted within 10 days. Reports must be submitted to reporting
authority in the state where the accident occurred. This form is provided to assist the operator in filing the required written report.
COMPLETE ALL BLOCKS
(indicate those not applicable by “NA”)
OPERATOR TELEPHONE NUMBER
NAME AND ADDRESS OF OPERATOR
NAME AND ADDRESS OF OWNER
AGE OF OPERATOR
DATE OF BIRTH
OWNER TELEPHONE NO.
RENTED BOAT
[ ] YES
[ ] NO
NUMBER OF
PERSONS ON
BOARD
OPERATOR’S EXPERIENCE
This type of boat
Other boat operating Exp.
[ ] Under 20 Hours
[ ] Under 20 Hours
[ ] 20 to 100 Hours
[ ] 20 to 100 Hours
[ ] 100 to 500 Hours
[ ] 100 to 500 Hours
[ ] Over 500 Hours
[ ] Over 500 Hours
FORMAL INSTRUCTION IN BOATING SAFETY
[ ] None
[ ] State
[ ] U.S. Power Squadrons
[ ] USCG Auxiliary
[ ] American Red Cross
[ ] Other (Specify)
VESSEL NO.
(this vessel)
BOAT REGISTER. NO.
BOAT NAME
BOAT MAKE
BOAT MODEL
MFR HULL IDENTIFICATION NO.
TYPE OF BOAT
[ ] Open Motorboat
[ ] Cabin Motorboat
[ ] Auxiliary Sail
[ ] Sail (only)
[ ] Rowboat
[ ] Canoe
[ ] Other (Specify)
HULL MATERIAL
[ ] Wood
[ ] Aluminum
[ ] Steel
[ ] Fiberglass
[ ] Rubber/vinyl
[ ] Other (Specify)
PROPULSION
No. of engines
Horse Power (total)
Type of fuel
CONSTRUCTION
Length
Year built (boat)
Has boat had a Safety Examination? [ ] Outboard [ ] NO
For current year?
[ ] YES
[ ] NO
Year
Indicate whether
[ ] USCG Auxiliary Courtesy Marine Exam
[ ] State/local examination [ ] Other
ACCIDENT DATA
DATE OF ACCIDENT
TIME
am
pm
NAME OF BODY OF WATER
LOCATION (Give location precisely)
Lat
Long
STATE
NEAREST CITY OR TOWN
COUNTY
WEATHER
[ ] Clear
[ ] Rain
[ ] Cloudy
[ ] Snow
[ ] Fog
[ ] Hazy
WATER CONDITIONS
[ ] Calm (waves less than 6")
[ ] Choppy (waves 6" to 2')
[ ] Rough (greater than 6')
[ ] Strong Current
TEMPERATURE
(Estimate)
Air
F
°
Water
F
°
WIND
[ ] None
[ ] Light (0 - 6mph)
[ ] Moderate (7 - 14 mph)
[ ] Strong (15 - 25 mph)
[ ] Storm (Over 25 mph)
VISIBILITY
DAY
NIGHT
[ ]
Good
[ ]
[ ]
Fair
[ ]
[ ]
Poor
[ ]
ENGINE
[ ] Outboard
[ ] Inboard gasoline
[ ] Inboard diesel
[ ] Inboard-outdrive
[ ] Jet
[ ] Other (Specify)
OPERATION AT TIME OF ACCIDENT
(Check all applicable)
[ ] Commercial Activity
[ ] Drifting
[ ] Cruising
[ ] At Anchor
[ ] Maneuvering
[ ] Tied to Dock
[ ] Approaching Dock
[ ] Fueling
[ ] Leaving Dock
[ ] Fishing
[ ] Water Skiing
[ ] Hunting
[ ] Racing
[ ] Skin Diving/
[ ] Towing
Swimming
[ ] Other (Specify)
[ ] Being Towed
TYPE OF ACCIDENT
(Check all applicable)
[ ] Grounding
[ ] Collision with
[ ] Capsizing
Fixed Object
[ ] Flooding
[ ] Collision with
[ ] Sinking
Floating Object
[ ] Fire or explosion (fuel) [ ] Falls Overboard
[ ] Fire or explosion
[ ] Falls in boat
(Other than fuel)
[ ] Hit by Boat or
[ ] Fallen Skier
Propeller
[ ] Collision with Vessel
[ ] Other (Specify)
WHAT IN YOUR OPINION CONTRIBUTED TO THE
ACCIDENT (Check all applicable)
[ ] Weather
[ ] Alcohol use
[ ] Excessive speed
[ ] Drug use
[ ] No Proper Lookout [ ] Fault of Hull
[ ] Restricted Vision
[ ] Fault of Machinery
[ ] Overloading
[ ] Fault of Equipment
[ ] Improper Loading
[ ] Hunting
[ ] Racing
[ ] Operator Inexperience
[ ] Hazardous Waters
[ ] Operator Inattention
[ ] Other (Specify)
PERSONAL FLOTATION DEVICES (PFDS)
PROPERTY DAMAGE
FIRE EXTINGUISHERS
Estimated amount
This boat $
Other boat $
Other Property $
Were they used? (If yes, list
Type(s) and number used.)
[ ] Yes [ ] No [ ] NA
Types:
DESCRIBE PROPERTY DAMAGE
NAME AND ADDRESS OF OWNER OF DAMAGED
PROPERTY
Was the boat adequately equipped with
COAST GUARD APPROVED FLOTATION
DEVICES?
[ ] Yes [ ] No
Were they accessible?
[ ] Yes [ ] No
Were they serviceable?
[ ] Yes [ ] No
Were they used by survivors? [ ] Yes [ ] No
What type? [ ] I, [ ] II, [ ] III, [ ] IV, [ ] V (specify)
Were PFD’s properly used?
[ ] Yes [ ] No
Adjusted
[ ] Yes [ ] No
Sized
[ ] Yes [ ] No
Include any comments of PFD’s under ACCIDENT DESCRIPTION on other side of form
Was the vessel carrying NON approved
flotation devices?
[ ] Yes [ ] No
Were they accessible?
[ ] Yes [ ] No
Were they used?
[ ] Yes [ ] No
If Yes, indicate kind.
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