Silverton 34C - Boating Accident Report

GLOSSARY-15
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; AN INJURY WHICH REQUIRES MEDICAL
TREATMENT BEYOND FIRST AID; OR PROPERTY DAMAGE IN EXCESS OF $2000 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 THE REPORTING AUTHORITY IN THE STATE WHERE THE ACCIDENT OCCURRED. THIS
FORM IS PROVIDED TO ASSIST THE OPERATOR IN FILING THE REQUIRED WRITTEN REPORT.
DEPARTMENT OF TRANSPORTATION
U.S. COAST GUARD CG-3865 (Rev. 9/95)
BOATING ACCIDENT REPORT
STATE ASSIGNED CASE NO._______________
COMPLETE ALL BLOCKS (INDICATE THOSE NOT APPLICABLE BY "NA")
ACCIDENT DATA
TIME AM
PM
DATE OF ACCIDENT
NAME OF BODY OF WATER LOCATION (GIVE LOCATION PRECISELY)
NUMBER OF VESSELS
INVOLVED
COUNTY STATE
ZIP CODE
NEAREST CITY OR TOWN
WEATHER
(CHECK ALL APPLICABLE)
[]CLEAR []RAIN
[ ] CLOUDY [ ] SNOW
[ ] FOG [ ] HAZY
WATER CONDITIONS
[ ] CALM (WAVES LESS THAN 6")
[ ] CHOPPY (WAVES 6" TO 2')
[ ] ROUGH (WAVES 2' TO 6')
[ ] VERY ROUGH (GREATER THAN 6')
[ ] STRONG CURRENT
TEMPERATURE
(ESTIMATE)
AIR_______
O
F
WATER_____
O
F
WIND
[ ] NONE
[ ] LIGHT (0-6 MPH)
[ ] MODERATE (7-14 MPH)
[ ] STRONG (15-25 MPH)
[ ] STORM (OVER 25 MPH)
VISIBILITY
DAY NIGHT
[]GOOD[]
[]FAIR []
[]POOR[]
NAME OF OPERATOR
OPERATOR TELEPHONE NUMBER
()
DATE OF BIRTH
MO DAY YR
OPERATOR'S EXPERIENCE
[]NONE
[ ] UNDER 100 HOURS
[ ] > 100 HOURS
INSTRUCTION IN BOATING SAFETY
[ ] STATE COURSE [ ] U.S. POWER SQUADRON
[ ] USCG AUXILIARY [ ] AMERICAN RED CROSS
[]NONE
[ ] MALE [ ] FEMALE
OPERATOR ADDRESS
NAME OF OWNER OWNER ADDRESS
OWNER TELEPHONE NUMBER
()
NUMBER OF PEOPLE
ON BOARD
NUMBER OF PEOPLE
BEING TOWED
RENTED BOAT?
[]YES []NO
BOAT NO. 1 (THIS VESSEL)
BOAT REGISTRATION OR DOCUMENTATION NUMBER STATE HULL IDENTIFICATION NUMBER BOAT NAME
BOAT MANUFACTURER LENGTH MODEL YEAR BUILT
TYPE OF BOAT
[ ] OPEN MOTORBOAT
[ ] CABIN MOTORBOAT
[ ] AUXILIARY SAIL
[ ] SAIL (ONLY)
[ ] ROWBOAT
[ ] CANOE/KAYAK
[ ] PERSONAL WATERCRAFT
[ ] PONTOON BOAT
[ ] HOUSEBOAT
[ ] OTHER (SPECIFY)
HULL MATERIAL
[ ] WOOD
[ ] ALUMINUM
[]STEEL
[ ] FIBERGLASS
[ ] RUBBER/VINYL/CANVAS
[ ] RIGID HULL INFLATABLE
[ ] OTHER (SPECIFY)
ENGINE
[ ] OUTBOARD
[]INBOARD
[]INBOARD-
STERNDRIVE (I/O)
[ ] AIRBOAT
PROPULSION
[]PROPELLER
[ ] WATER JET
[ ] AIR THRUST
[ ] MANUAL
[]SAIL
PERSONAL FLOTATION DEVICES
(PFDS): WAS BOAT ADEQUATELY
EQUIPPED WITH COAST GUARD
APPROVED PFDS?
[]YES []NO
WERE PFDS ACCESSIBLE?
[]YES []NO
NUMBER OF
ENGINES
TOTAL
HORSEPOWER
FIRE EXTINGUISHERS
ON BOARD? []YES []NO
USED? []YES []NO
FUEL
[ ] GASOLINE
[ ] DIESEL
[ ] ELECTRIC
OPERATION AT TIME OF ACCIDENT
(CHECK ALL APPLICABLE)
[ ] CRUISING
[ ] CHANGING DIRECTION
[ ] CHANGING SPEED
[ ] DRIFTING
[ ] TOWING
[ ] BEING TOWED
[ ] ROWING/PADDLING
[ ] SAILING
[ ] LAUNCHING
[ ] DOCKING/UNDOCKING
[ ] AT ANCHOR
[ ] TIED TO DOCK/MOORED
[ ] OTHER (SPECIFY)
ACTIVITY AT TIME OF ACCIDENT
(CHECK ANY IF APPLICABLE)
[ ] FISHING
[ ] TOURNAMENT
[ ] HUNTING
[ ] SWIMMING/DIVING
[ ] MAKING REPAIRS
[ ] WATERSKIING/TUBING/ETC.
[]RACING
[ ] WHITEWATER SPORTS
[ ] FUELING
[ ] STARTING ENGINE
[ ] NON-RECREATIONAL
[ ] OTHER (SPECIFY)
TYPE OF ACCIDENT
[ ] GROUNDING
[]CAPSIZING
[ ] FLOODING/SWAMPING
[]SINKING
[ ] FIRE OR EXPLOSION (FUEL)
[ ] FIRE OR EXPLOSION (OTHER)
[ ] SKIER MISHAP
[ ] COLLISION WITH VESSEL
[ ] COLLISION WITH FIXED OBJECT
[ ] COLLISION WITH FLOATING OBJ.
[ ] FALLS OVERBOARD
[ ] FALLS IN BOAT
[ ] STRUCK BY BOAT
[ ] STRUCK BY MOTOR/PROPELLER
[ ] STRUCK SUBMERGED OBJECT
[ ] OTHER (SPECIFY)
[ ] HIT AND RUN
ESTIMATED SPEED [ ] NONE [ ] UNDER 10 MPH
[ ] 10 - 20 MPH [ ] 21 - 40 MPH [ ] OVER 40 MPH
FORM APPROVED OMB NO. 2115-0010
WHAT CONTRIBUTED TO ACCIDENT?
(CHECK ALL APPLICABLE)
[ ] WEATHER
[ ] EXCESSIVE SPEED
[ ] IMPROPER LOOKOUT
[ ] RESTRICTED VISION
[ ] OVERLOADING
[ ] IMPROPER LOADING
[ ] HAZARDOUS WATERS
[ ] ALCOHOL USE
[]DRUG USE
[ ] HULL FAILURE
[ ] MACHINERY FAILURE
[ ] EQUIPMENT FAILURE
[ ] OPERATOR INEXPERIENCE
[ ] OPERATOR INATTENTION
[ ] CONGESTED WATERS
[ ] PASSENGER/SKIER BEHAVIOR
[ ] DAM/LOCK
[ ] OTHER (SPECIFY)