PURSUIT 2670 Denali Owner's Manual download pdf (Page 122)

2670 Denali

122

If more than 3 fatalities and/or injuries, attach additional form(s)

WAS VICTIM?

[ ] Swimmer

[ ] Non Swimmer

DATE OF

BIRTH

ADDRESSNAME DEATH CAUSED BY

[ ] Drowning

[ ] Other

[ ] DISAPPEARANCE

WAS PFD WORN?

[ ] Yes [ ] No

What Type?

WAS VICTIM?

[ ] Swimmer

[ ] Non Swimmer

DATE OF

BIRTH

ADDRESSNAME DEATH CAUSED BY

[ ] Drowning

[ ] Other

WAS PFD WORN?

[ ] Yes [ ] No

What Type?

WAS VICTIM?

[ ] Swimmer

[ ] Non Swimmer

DATE OF

BIRTH

ADDRESSNAME DEATH CAUSED BY

[ ] Drowning

[ ] Other

WAS PFD WORN?

[ ] Yes [ ] No

What Type?

[ ] DISAPPEARANCE

ADDRESSNAME

NATURE OF INJURYDATE OF

BIRTH

DATE OF

BIRTH

DATE OF

BIRTH

NATURE OF INJURY

MEDICAL TREATMENT

DESCRIBE WHAT HAPPENED (Sequence of events. Include Failure of Equipment. If diagram is needed, attach separately. Continue on additional sheets

if necessary. Include any information regarding the involvement of alcohol and/or drugs in causing or contributing to the accident. Include any descriptive

information about the use of PFD's.)

INJURED

VESSEL NO. 2 (if more than 2 vessels, attach additional form (s)

DECEASED

ACCIDENT DESCRIPTION

Name of Owner

Telephone Number

Name of Operator

Address

Name

Address

Boat Name

Boat Number

Telephone Number

Date Submitted

Date Received

Reviewed By

Address

SIGNATURE

QUALIFICATION (Check One)

[ ] Operator [ ] Owner [ ] Investigator [ ] Other

Causes based on (check one)

[ ] This report [ ] Investigation and this report

[ ] Investigation [ ] Could not be determined

Primary Cause of Accident

Secondary Cause of Accident

Name of Reviewing Office

(do not use) - FOR REPORTING AUTHORITY REVIEW (use agency date stamp)

WITNESSES

BOATING ACCIDENT REPORT

1 2 ... 117 118 119 120 121 122 123 124 125 126 127 ... 139 140

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