b'BOATING ACCIDENT REPORTSTATE OF CONNECTICUT PREVIOUS EDITIONS ARE OBSOLETEDEPARTMENT OF ENERGY & ENVIRONMENTAL PROTECTION Revised 9/2016 BUREAU OF OUTDOOR RECREATIONBOATING DIVISION P.O. BOX 280, OLD LYME CT 06371-0280 POLICE DEPARTMENT NAME AND CASE NO. (If any) (860) 434-8638 or FAX (860) 434-3501The operator of a vessel used for recreational purposes is required to file a report in writing within 48 hours whenever an accident results in loss of life, disappearance from a vessel or injury which requires medical attention beyond first aid. If total damage to all property is in excess of $500, a report must be filed within 5 days. Reports shall be submitted to the commissioner of Energy and Environmental Protection at the above address. If the operator is unable to report the accident, the boat owner or survivor of the accident should prepare the report. Any person violating these requirements is subject to the penalties prescribed by law.YOUR VESSEL INFORMATION (Vessel # 1) COMPLETE ALL BLOCKS (Indicate those not applicable by "N/A"NAME AND ADDRESS OF OPERATOR AGE D.O.B. GENDER OPERATOR\'S EXPERIENCE ON THIS VESSEL OPERATOR\'S FORMAL M F Under 20 hours 100 to 500 hours BOATING INSTRUCTION 20 to 100 hours Over 500 hours (Check all that apply)unknown NoneOPERATOR\'S PHONE NUMBER State CourseOPERATOR\'S EXPERIENCE ON OTHER VESSELS USCG Aux. CourseUnder 20 hours 100 to 500 hours US Power SquadronsOPERATOR\'S SAFE BOATING OR PWC CERTIFICATE # 20 to 100 hours Over 500 hours Other ___________unknown unknownNAME AND ADDRESS OF OWNER SAME AS ABOVE RENTED BOAT? NUMBER OF PEOPLE ON BOARD NUMBER OF PEOPLE BEING TOWED Y N ex. skier, tuberREGISTRATION NUMBER STATE MAKE MODEL & YEAR HULL INDENTIFICATION NUMBER BOAT NAMETYPE OF VESSEL HULL MATERIAL ENGINE TYPE PROPULSION ENGINES LENGTH BEAM (Width) DEPTH FROM TRANSOM TO KEELAir Boat Paddlecraft Aluminum Inboard Propeller ft. ft. ft.Auxiliary Sail PWC Fiberglass Outboard Manual No.Cabin Motorboat Pontoon Boat Rubber/Vinyl/Canvas Pod Drive Water JetHouseboat Rowboat Plastic Sterndrive Sail FUEL TYPEInflatable Boat Sail ONLY Steel Other Air Thrust TotalGasoline ElectricOpen Motorboat Other Wood Other HPOther ___________ Diesel OtherSAFETY EQUIPMENT ON VESSELPERSONAL FLOTATION DEVICES Were They USCG approved? Yes No HAS VESSEL HAD A VESSEL SAFETY CHECK WITHIN THE PAST YEAR?Number of Life Were They Used? Yes No Yes No Given A VSC Sticker? Yes NoJackets Onboard:WereThey Accessible? Yes NoORGANIZATION THAT CONDUCTED THE VESSEL SAFETY CHECKFIRE EXTINGUISHERS Were They Used? Yes No USCG Auxiliary US Power Squadrons DEEP OtherNumber of Fire Extinguishers and Type:ACCIDENT DETAILSDATE OF ACCIDENT TIME AM # VESSELS INVOLVED NAME OF WATER BODY EXACT LOCATIONIf possible, provide Latitude and LongitudeNEAREST TOWNPMWEATHER CONDITIONS WAVE CONDITIONS WIND VISIBILITY EST. AIR TEMP STRONG CURRENT? WEATHER ENCOUNTERED?Good Poor Yes No was as forecastClear Raining Calm (Under 6in.) None F CONGESTED WATERS? not as forecastCloudy Hazy Choppy (6in. - 2ft.) Light (0 - 12 mph) Fair Yes No no forecast obtainedFoggy Snowing Rough (2ft. - 6ft.) Moderate (12- 25 mph) TIME OF DAY EST. WATER TEMP HAZARDOUS WATERS? NoneStrong (25- 55 mph) Yes NoOther Very Rough (over 6ft.) Stormy (over 55 mph) Day Night F OtherESTIMATED SPEED OPERATOR/PASSENGERACCIDENT EVENTS (Check all applicable) CONTRIBUTING FACTORS (check all applicable)0 - 10 mph None ACTIVITIES (Check all applicable) Collision w/ Recreational Vessel Alcohol Use People on Gunwale/Bow/Transom11 -20 mph Recreational Collision w/ Commercial Vessel Drug Use Force of Wake/Wave21 - 40 mph Collision w/ Fixed Object Hazardous Waters Heavy WeatherOver 40 mph Commercial Collision w/ Floating Object Excessive Speed Sharp TurnCollision w/Submerged Object Improper Anchoring Hull FailureOPERATION AT TIME OF ACCIDENTSinking Improper Loading Starting in Gear(Check all applicable) Fishing Grounding Overloading Restricted Vision (ex., fog)Cruising(underway under power) Hunting Capsizing Improper Lookout Missing/Inadequate Aids to Nav.Changing Direction White Water Activity Flooding / Swamping Operator Inattention Inadequate On-Board Nav. LightsChanging Speed Tubing Fire / Explosion (Fuel) Operator Inexperience Dam/LockRacing WaterskiingFire / Explosion (Non- Fuel) Language Barrier Other (describe)Sailing Starting Engine Person Electrocuted Navigation Rules ViolationAt Anchor Making Repairs Carbon Monoxide Exposure Failure to VentTied to Dock / Mooring Relaxing Person Struck By Vessel Ignition of FuelorVaporsRowing / Paddling Other: (list) Person Fell Overboard Machinery Failure Equipment FailureDrifting Person Struck By PropellerBeing Towed Sudden Medical Condition (check applicable below) (check applicable below)Towing Another Vessel Person Fell On/Within Vessel Engine Sail/MastAuxiliary EquipmentLaunching Mishap of Skier, Tuber, wake brd Electrical Sys.SeatsFire ExtinguisherDocking / Undocking Person Left Vessel Voluntarily Fuel System On-Board Lights Sound Equip . (ex. horn)Other: (list) Person Ejected from Vessel Radio Ventilation Other:Other (describe) Throttle SteeringShift On-Board Nav. Aids (ex., GPS)2020 Connecticut BOATERS GUIDE65'