Silverton 34C - Page 168

GLOSSARY-16
NAME OF VICTIM ADDRESS OF VICTIM
[]MALE[]FEMALE
DEATH CAUSED BY [ ] DROWNING [ ] OTHER [ ] DISAPPEARANCE
WAS PFD WORN?
[]YES
[]NO
ADDRESS OF VICTIM
WAS PFD WORN?
[]YES
[]NO
DECEASED (IF MORE THAN 2 FATALITIES, ATTACH ADDITIONAL FORMS)
INJURED (IF MORE THAN 2 INJURIES, ATTACH ADDITIONAL FORMS)
ADDRESS OF VICTIM
MEDICAL TREATMENT BEYOND FIRST AID? [ ] YES [ ] NO
ADMITTED TO HOSPITAL? [ ] YES [ ] NO
DESCRIBE INJURY
NAME OF VICTIM
DATE OF BIRTH
DATE OF BIRTH
WAS PFD WORN? [ ] YES [ ] NO PRIOR TO ACCIDENT? [ ] YES [ ] NO AS A RESULT OF ACCIDENT? [ ] YES [ ] NO
WAS IT INFLATABLE? [ ] YES [ ] NO
ADDRESS OF VICTIM
DESCRIBE INJURY
OTHER PEOPLE ABOARD THIS BOAT (IF MORE THAN 2 PEOPLE, ATTACH ADDITIONAL FORMS)
ADDRESS
NAME
WAS PFD WORN? [ ] YES [ ] NO PRIOR TO ACCIDENT? [ ] YES [ ] NO
AS A RESULT OF ACCIDENT [ ] YES [ ] NO WAS IT INFLATABLE? [ ] YES [ ] NO
ADDRESS
NAME
BOAT NO. 2 (IF MORE THAN 2 VESSELS, ATTACH ADDITIONALIDENTIFYING INFORMATION)
OPERATOR ADDRESS
BOAT REGISTRATION OR DOCUMENTATION NUMBER
STATE
WAS PFD WORN? [ ] YES [ ] NO PRIOR TO ACCIDENT? [ ] YES [ ] NO AS A RESULT OF ACCIDENT? [ ] YES [ ] NO
WAS IT INFLATABLE? [ ] YES [ ] NO
NAME OF VICTIM
DATE OF BIRTH
MEDICAL TREATMENT BEYOND FIRST AID? [ ] YES [ ] NO
ADMITTED TO HOSPITAL? [ ] YES [ ] NO
NAME OF VICTIM
DATE OF BIRTH
[]MALE[]FEMALE
DEATH CAUSED BY [ ] DROWNING [ ] OTHER [ ] DISAPPEARANCE
OWNER TELEPHONE NUMBER
()
NAME OF OPERATOR
DATE OF BIRTH
DATE OF BIRTH
OPERATOR TELEPHONE NUMBER
()
NAME OF OWNER
PROPERTY DAMAGE
ESTIMATED AMOUNT: THIS BOAT AND CONTENTS: OTHER BOAT(S) AND CONTENTS: OTHER PROPERTY:
$$ $
DESCRIBE PROPERTY DAMAGED
WITNESSES NOT ON THIS VESSEL
NAME
OWNER ADDRESS
NAME
ADDRESS
ADDRESS
TELEPHONE NUMBER
()
TELEPHONE NUMBER
()
PERSON COMPLETING REPORT
NAME
ADDRESS
TELEPHONE NUMBER
()
SIGNATURE
QUALIFICATION [ ] OPERATOR [ ] OWNER
[ ] INVESTIGATOR [ ] OTHER
DATE SUBMITTED
FOR AGENCY USE ONLY
CAUSES BASED ON (CHECK ONE): [ ]THIS REPORT [ ] INVESTIGATION [ ] INVESTIGATION AND THIS REPORT [ ] OTHER
NAME OF REVIEWING OFFICE
DATE RECEIVED
RECREATIONAL [ ] NON-REPORTABLE [ ]
COMMERCIAL [ ]
PRIMARY CAUSE SECONDARY CAUSE
WAS PFD WORN? [ ] YES [ ] NO PRIOR TO ACCIDENT? [ ] YES [ ] NO
AS A RESULT OF ACCIDENT [ ] YES [ ] NO WAS IT INFLATABLE? [ ] YES [ ] NO