Hunter MH37 - Page 32

Documents and Forms
2.12
DEPARTMENT OF HOMELAND SECURITY
U.S. Coast Guard OMB Control Number: 1625-
0003
RECREATIONAL BOATING ACCIDENT REPORT ([SLUHV
INSTRUCTIONS: Use "Report required because" section below to determine if a report is required for your accident. If required, please have each vessel
owner or operator involved in the accident submit a report to their state reporting authority. Each boat operator/owner involved in an accident should submit
a separate report. For each question below, please provide answers if applicable and if known; otherwise leave blank.
Privacy Act Notice: Authority- 46
U.S.
C. 6102 and 33 CFR 173 & 174 authorize the collection of information on boating accidents. Purpose-The Coast Guard uses this information for statistical
purposes, chiefly to inform the public, to measure the Program's efforts, and to regulate issues relating to boating safety. Routine Uses-The Coast Guard
shares this information within the agency, and if state and federal law permit it, to the public.
REPORT SUBMISSION
Report required because VHOHFWDOOWKDWDSSO\
At least one person in this accident GLHG: If so, how many? _______
At least one injured person in this accident UHTXLUHGRUZDVLQQHHGRI
WUHDWPHQWEH\RQGILUVWDLG: If so, how many?
_______
At least one person in this accident GLVDSSHDUHGand has not yet been
recovered: If so, how many? _______
$OOboat and other property GDPDJHHJILVKLQJKXQWLQJJHDUcaused
by this accident WRWDOHGRUOLNHO\WRWDOHG$2,000 or more:
Approximate value of damage to \RXUboat: $_____
_____
Approximate value of damage to \RXUother property: $__________
Your or another ERDWin this accident was RUOLNHO\ZDVa WRWDOORVV
Report submitted by VHOHFWDOOWKDWDSSO\:
Boat Operator UHTXLUHGLISRVVLEOH
Boat Owner LIRSHUDWRUXQDEOHRUVDPHDVRSHUDWRU
Other GHVFULEH:
__________________________________________
__________________________________________
To be submitted within:
48 hours LILQMXU\GLVDSSHDUDQFHRUGHDWK
10 days LIERDWSURSHUW\GDPDJHRQO\
To be submitted to: /RFDO6WDWH5HSRUWLQJ
$XWKRULW\
Phone:
You may submit any comments concerning the accuracy of the
burden estimate or any suggestions for reducing the burden to:
Commandant (CG-5422), U.S. Coast Guard, Washington, DC
20593-0001 or Office of Management and Budget, Paperwork
Reduction Project (1625-0003), Washington, DC 20503. Questions
relating to the collection of this data should be sent to the Coast
Guard.
For State Agency Use Only
)LUVW1DPH
/DVW1DPH
3KRQH:
First Name
Last Name
Phone
3ULPDU\&DXVHRI$FFLGHQW
ACCIDENT SUMMARY
WHEN
ACCIDENT DESCRIPTION:
%ULHIO\describe this accident
DWWDFKH[WUDSDJHVL
IQHFHVVDU\
Date: Time: am pm
PPGG\\\\ VHOHFWRQH
WHERE
Body of Water Name
Location RQZDWHUdescription
DAMAGE TO YOUR BOAT:
%ULHIO\
summarize any damage to
your boat
Nearest city/town
County:
State:
YOUR BOAT – PEOPLE
DAMAGE TO YOUR OTHER PROPERTY: (NOT BOAT)
%ULHIO\
summarize any damage to your other property QRWERDW
# people RQERDUGLQFOXGLQJRSHUDWRU:
# pe
ople EHLQJWRZHGHJRQWXEHVVNLV:
# people ZHDULQJOLIHMDFNHWVRQERDUGRUWRZHG:
OTHER BOATS INVOLVED IN ACCIDENT
# of RWKHUboats involved:
CG-3865 (1/11) Page 1 of 6
Figure 2.5