CALIFORNIA BOATING ACCIDENT REPORT
|CALIFORNIA BOATING ACCIDENT REPORT CALIFORNIA STATE PARKS, DIVISION OF BOATING AND WATERWAYS |
|The operator of every recreational vessel is required by Section 656 of the Harbors and Navigation Code to file a written report whenever a boating accident occurs which |
|results in death, disappearance, injury that requires medical attention beyond first aid, total property damage in excess of $500, or complete loss of a vessel. Reports must|
|be submitted within 48 hours in case of death occurring within 24 hours of an accident, disappearance, or injury beyond first aid. All other reports must be submitted within|
|10 days of the accident. Reports are to be submitted to California State Parks, Division of Boating and Waterways, Accident Unit at P.O. Box 942896, Sacramento, California |
|94296-0001, (916) 327-1826. Failure to submit this report as required is a misdemeanor and is punishable by a fine not to exceed $1000 or imprisonment not to exceed 6 months|
|or both. |
|DATE OF ACCIDENT (M/D/Y) |TIME OF ACCIDENT |COUNTY |STATE |BODY OF WATER |NEAREST CITY OR TOWN |
| | | | | | |
| | |
|# INJURED |# DEAD |TOTAL $$ |LAW ENFORCEMENT ON ACCIDENT SCENE? |AGENCY NAME |
| | | |YES NO | |
|TEMPERATURE |WATER CONDITIONS |WIND CONDITIONS |FORECAST AVAILABLE? YES NO USED? YES|
|WATER AIR |CALM (Waves less than 6”) |NONE |NO |
| |CHOPPY (Waves 6”-2’) |LIGHT (0-6 MPH) | |
| |ROUGH (Waves 2’-6’) |MODERATE (7-14 MPH) | |
| |VERY ROUGH (Waves >6’) |STRONG (15-25 MPH) | |
| | |STORM (OVER 25 MPH) | |
|WEATHER (CHECK ALL THAT APPLY) | | |WEATHER FORECAST |
| | | | |
| | | |AVAILABLE USED |
| | | |BEFORE VOYAGE YES NO YES NO |
| | | |DURING VOYAGE YES NO YES NO |
| | | |AFTER VOYAGE YES NO YES NO |
| CAPSIZING | | | |
|CLOUDY | | | |
|FOG | | | |
|RAIN | | | |
|SNOW | | | |
|HAZY | | | |
| | | |VISIBILITY |STRONG CURRENT |
| | | |GOOD FAIR POOR |YES NO |
|TYPE OF ACCIDENT (CHECK ALL THAT APPLY) |CAUSE OF ACCIDENT (CHECK ALL THAT APPLY) |ACTIVITY AT TIME OF ACCIDENT |
| |#1 #2 |#1 #2 |
|CAPSIZING |IMPROPER LOOKOUT/INATTENTION |WATER SKIING |
|COLLISION WITH VESSEL |OPERATOR INEXPERIENCE |WAKE BOARDING |
|COLLISION WITH FIXED OBJECT |EXCESSIVE SPEED |TUBING |
|COLLISION WITH FLOATING OBJECT |MACHINERY FAILURE |FISHING |
|FALL OVERBOARD |IMPROPER LOADING |RACING |
|FALL IN BOAT |OVERLOADING |WHITEWATER ACTIVITY |
|GROUNDING |EQUIPMENT FAILURE (DESCRIBE): |FUELING |
|FIRE/EXPLOSION (fuel) | |HUNTING |
|FIRE/EXPLOSION (other than fuel) |HAZARDOUS WEATHER/WATER |OTHER: |
|FLOODING/SWAMPING |RESTRICTED VERSION | |
|SINKING |IGNITION OF SPILLED FUEL/VAPOR | |
|STRUCK BY BOAT/PROPELLER |IMPROPER ANCHORING | |
|SKIER MISHAP |OFF-THROTTLE STEERING INABILITY | |
|OTHER: |FAILURE TO VENT | |
| |OTHER: | |
| | | |
| | |DID DRUGS OR ALCOHOL CONTRIBUTE TO THE ACCIDENT? |
| | |ALCOHOL YES NO UNKNOWN |
| | |DRUGS YES NO UNKNOWN |
| | |IF YOU MARKED “YES,” PLEASE PROVIDE DETAILS IN NARRATIVE. |
|DESCRIBE WHAT HAPPENED AND WHAT YOU COULD HAVE DONE TO PREVENT THIS ACCIDENT |
|(Explain the cause of death or injury, medical treatment, etc. Use sketch if helpful. If needed, continue description on additional paper.) |
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|OTHER PROPERTY |
|(Damage to items other than vessels) |
|DESCRIPTION OF DAMAGE |ESTIMATED DAMAGE $$ |
| |NONE |
| | |
|OWNER’S NAME ADDRESS STATE ZIP |PHONE |NOTIFIED |
| |( ) |YES NO |
|VICTIM OR WITNESS INFORMATION |
|VICTIM/WITNESS |
|NAME/ADDRESS/PHONE |
|INFORMATION: OPERATOR #1 |
|OPERATOR NAME, ADDRESS, PHONE # |IS OWNER DIFFERENT THAN OPERATOR? YES NO |OPERATOR EXPERIENCE |OPERATOR EDUCATION |
| | |UNDER 10 HOURS |AMERICAN RED CROSS |
| | |10 TO 100 HOURS |USCG AUXILARY |
| | |OVER 100 HOURS |US POWER SQUADRON |
| | | |STATE COURSE |
| | | |INFORMAL |
| | | |NONE |
| | | |OTHER: |
| |OWNER NAME AND ADDRESS | | |
| | | | |
|AGE |MARINA/RAMP LAUNCHED FROM: |
| INFORMATION: VESSEL #1 (YOUR VESSEL) |
|THIS |# INJURED |# DEAD |ESTIMATED DAMAGE |RENTED BOAT |# OF PERSONS ON BOARD |
|VESSEL | | | |YES NO | |
|ONLY | | | | | |
|BOAT MANUFACTURER |BOAT MODEL |YEAR BUILT |SPEED AT TIME OF ACCIDENT |# OF ENGINES |HORSE POWER |
| | | | MPH | | |
|ACTIVITY |FIRE |TYPE OF FIRE |FIRE EXTINGUISHER USED |LIFE JACKETS ON BOARD |
|RECREATIONAL |EXTINGUISHER |EXTINGUISHER |YES NO |YES NO |
|COMMERCIAL |ON BOARD | | | |
|OTHER |YES NO |# ONBOARD | | |
| | | | | |
| | |ENGINE TYPE (select one) | | |
| | |OUTBOARD | | |
| | |STERNDRIVE (I/O) | | |
| | |INBOARD | | |
| | |POD DRIVE | | |
| | |NONE | | |
| | |OTHER: | | |
| | |TOTAL HORSEPOWER: HP | | |
|INFORMATION: OPERATOR #2 |
|OPERATOR NAME, ADDRESS, PHONE # |IS OWNER DIFFERENT THAN OPERATOR? YES NO |OPERATOR EXPERIENCE |OPERATOR EDUCATION |
| | |UNDER 10 HOURS |AMERICAN RED CROSS |
| | |10 TO 100 HOURS |USCG AUXILARY |
| | |OVER 100 HOURS |US POWER SQUADRON |
| | | |STATE COURSE |
| | | |INFORMAL |
| | | |NONE |
| | | |OTHER: |
| |OWNER NAME AND ADDRESS | | |
| | | | |
|AGE |MARINA/RAMP LAUNCHED FROM: |
| INFORMATION: VESSEL #2 (OTHER VESSEL INVOLVED) |
|THIS |# INJURED |# DEAD |ESTIMATED DAMAGE |RENTED BOAT |# OF PERSONS ON BOARD |
|VESSEL | | | |YES NO | |
|ONLY | | | | | |
|BOAT MANUFACTURER |BOAT MODEL |YEAR BUILT |SPEED AT TIME OF ACCIDENT |# OF ENGINES |HORSE POWER |
| | | | MPH | | |
|ACTIVITY |FIRE |TYPE OF FIRE |FIRE EXTINGUISHER USED |LIFE JACKETS ON BOARD |
|RECREATIONAL |EXTINGUISHER |EXTINGUISHER |YES NO |YES NO |
|COMMERCIAL |ON BOARD | | | |
|OTHER |YES NO |# ONBOARD | | |
| | | | | |
| | |ENGINE TYPE (select one) | | |
| | |OUTBOARD | | |
| | |STERNDRIVE (I/O) | | |
| | |INBOARD | | |
| | |POD DRIVE | | |
| | |NONE | | |
| | |OTHER: | | |
| | |TOTAL HORSEPOWER: HP | | |
|PERSON COMPLETING THE REPORT |
|NAME |ADDRESS |PHONE ( ) |QUALIFICATION OF PERSON COMPLETING REPORT |
| | | |OPERATOR OWNER |
| | | |OTHER (specify) |
|SIGNATURE DATE | |
DBW FORM BAR-1 08/14 THIS CONFIDENTIAL REPORT IS USED IN RESEARCH FOR THE PREVENTION OF ACCIDENTS AND A COPY IS FORWARDED TO THE UNITED STATES COAST GUARD
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