PURSUIT 2470 WALKAROUND Owner's Manual download pdf (Page 127)

2470 WALKAROUND

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

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.

Appendix C:

C-1

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