b"INJURED / MISSING / DECEASEDNAME AND ADDRESS OF VICTIM AGE D.O.B. GENDER ONBOARD VESSEL WAS A PFD WORN? Treatment Beyond 1st AidM F Yes No Victim Was HospitalizedDEATH CAUSED BY: (If applicable) OtherMISSING TYPE OF INJURY LOCATION OF INJURYDrowning Trauma _____ Y NNAME AND ADDRESS OF VICTIM AGE D.O.B. GENDER ONBOARD VESSEL WAS A PFD WORN? Treatment Beyond 1st AidM F Yes No Victim Was HospitalizedDEATH CAUSED BY: (If applicable) MISSING TYPE OF INJURY LOCATION OF INJURYDrowning Trauma Other Y NNAME AND ADDRESS OF VICTIM AGE D.O.B. GENDER ONBOARD VESSEL WAS A PFD WORN? Treatment Beyond 1st AidM F Yes No Victim Was HospitalizedDEATH CAUSED BY: (If applicable) MISSING TYPE OF INJURY LOCATION OF INJURYDrowning Trauma Other Y NNOTE: If more space is needed to list information concerning Injured / Missing / Deceased persons please attach a separate page. PROPERTY DAMAGEPROPERTY DAMAGE ESTIMATE PROPERTY DAMAGE DESCRIPTION $Vessel #1 $ Vessel Was A Loss.Vessel's ValueVessel #2 $Other Property $ACCIDENT DESCRIPTIONDESCRIBE WHAT HAPPENED (Include a sequence of events and what in your opinion caused the accident.Include or attach a diagram if needed. Continue on additional sheets of paper if necessary.)ALCOHOL / DRUG USEDid the operator consume any alcohol or do drugs before or during the operation of the vessel? A Little A Lot None Alcohol Drugs BothDid any of the passengers consume any alcohol or do drugs before or during the operation of theA Little A Lot None Alcohol Drugs Bothvessel?Was there any alcohol or drugs onboard during the operation of the vessel? A Little A Lot None Alcohol Drugs BothIf this accident involved more than one vessel, was there any indication that the operator of the otherA Little A Lot None Alcohol Drugs Bothvessel(s) had consumed any alcohol or done drugs?OTHER VESSEL (Vessel #2)If more than 2 vessels were involved, please attach a separate sheet of paper with this information.NAME AND ADDRESS OF OPERATOR AGE D.O.B. GENDER REGISTRATION NUMBER STATE MANUFACTURERM FOPERATOR'S PHONE NUMBER BOAT NAME HULL INDENTIFICATION NUMBERTYPE OF VESSEL (Use categories from page 1) LENGTH (approx.) OPERATION (Use categories from page 1) RENTED BOAT?ft. Yes NoNAME, ADDRESS, AND PHONE NUMBER OF OWNER SAME AS ABOVE NUMBER OF PEOPLE ON BOARDSIGNATUREThe information on this form is certified under penalty of false statement to be true and complete.X Signature of person completing this report Date Printed name of person completing this reportAddress (Street, Town, State) PhoneINVOLVEMENT: Operator OwnerWitness: Other:This form is available on-line in a PDF version you can fill out on your computer. Visit: www.ct.gov/deep/boating662020 Connecticut BOATERS GUIDE"