DEPARTMENT OF BOATING AND WATERWAYS - California



|VESSEL ACCIDENT REPORT CALIFORNIA STATE PARKS, DIVISION OF BOATING AND WATERWAYS PAGE     OF     |

|AGENCY NAME TAKING REPORT |NO INJURED |NO KILLED |AGENCY REPORT NUMBER |

|      |      |      |      |

|LOCATION|WATERBODY ACCIDENT OCCURRED ON |NEAREST CITY OR TOWN |MONTH DAY |TIME (2400) |

| |      |      |YEAR |      |

| | | |   |   |     | |

| |COUNTY ACCIDENT OCCURRED IN |NEAREST LANDMARK (NAVIGATION AID) |INVESTIGATED BY PHONE       |

| |      |          FEET/MILES OF |      |

| |LATITUDE/LONGITUDE THAT ACCIDENT OCCURRED |

|PARTY |NAME (FIRST, MIDDLE, LAST) |STREET / MAILING ADDRESS |

|# 1 |      |      |

| |IDENTIFICATION |DOB / AGE |SEX |CITY |PHONE (   ) |

| |      |         |MALE |STATE ZIP |      |

| | | |FEMALE |      | |

|OPERATOR| | | | | |

|SWIMMER |VESSEL YEAR |MAKE / MODEL / LENGTH |VESSEL NUMBER (CF OR DOC) |VESSEL NAME |ACTIVITY | |

| |      |      |      |      |RECREATIONAL |WORKBOAT |

| | | | | |COMMERCIAL |OTHER       |

|MOORED |HULL IDENTIFICATION NUMBER |HORSEPOWER |RENTED |OWNER’S NAME |PHONE (   ) |

|VESSEL |NONE |      |YES |SAME |      |

| |      | |NO |      | |

| |DIRECTION OF TRAVEL |# PERSONS ON|MARINA/RAMP |VESSEL DAMAGE |OWNER’S STREET / MAILING ADDRESS |

| |      |BOARD |LAUNCHED FROM: | |SAME |

| | |    |      | |      |

| | | |OTHER: | | |

| | | |      | | |

|OTHER | | | | MINOR | MAJOR | |

| | | | |MODERATE |TOTAL | |

| |EST. SPEED |DISPOSITION OF VESSEL | |ESTIMATED DAMAGE $ NONE |CITY STATE |

| |    |      | |      |ZIP |

| | | | | |      |

|PARTY |NAME (FIRST, MIDDLE, LAST) |STREET / MAILING ADDRESS |

|# 2 |      |      |

| |IDENTIFICATION |DOB / AGE |SEX |CITY |PHONE (   ) |

| |      |         |MALE |STATE ZIP |      |

| | | |FEMALE |      | |

|OPERATOR| | | | | |

|SWIMMER |VESSEL YEAR |MAKE / MODEL / LENGTH |VESSEL NUMBER (CF OR DOC) |VESSEL NAME |ACTIVITY | |

| |      |      |      |      |RECREATIONAL |WORKBOAT |

| | | | | |COMMERCIAL |OTHER       |

|MOORED |HULL IDENTIFICATION NUMBER |HORSEPOWER |RENTED |OWNER’S NAME |PHONE (   ) |

|VESSEL |NONE |      |YES |SAME |      |

| |      | |NO |      | |

| |DIRECTION OF TRAVEL |# PERSONS ON|MARINA/RAMP |VESSEL DAMAGE |OWNER’S STREET / MAILING ADDRESS |

| |      |BOARD |LAUNCHED FROM: | |SAME |

| | |    |      | |      |

| | | |OTHER: | | |

| | | |      | | |

|OTHER | | | | MINOR | MAJOR | |

| | | | |MODERATE |TOTAL | |

| |EST. SPEED |DISPOSITION OF VESSEL | |ESTIMATED DAMAGE $ NONE |CITY STATE |

| |    |      | |      |ZIP |

| | | | | |      |

|OTHER |DESCRIPTION OF DAMAGE |ESTIMATED DAMAGE $ NONE |

|PROPERTY|      |      |

| |OWNER’S NAME ADDRESS STATE |PHONE (   ) |NOTIFIED |

| |ZIP |      |YES NO |

| |      | | |

|INJURED/DECEASED/WITNESS |VICTIM / WITNESS |

| |NAME, ADDRESS & PHONE |

| | CALIFORNIA STATE PARKS |

| |DIVISION OF BOATING AND WATERWAYS |

| |ACCIDENT UNIT |

| |P.O. BOX 942896 |

| |SACRAMENTO, CA 94296-0001 |

DBW FORM VAR-1 (08/14)

|VESSEL ACCIDENT REPORT CALIFORNIA STATE PARKS, DIVISION OF BOATING AND WATERWAYS PAGE     OF     |

|WEATHER |WATER CONDITIONS |WAVE SIZE |WIND |

| | |#1 | |#1 | |#1 | |

| |CAPSIZING |#2 |IMPROPER LOOKOUT / INATTENTION |#2 |CRUISING |#2 |HAD NOT BEEN DRINKING |

| | | | | | | | |

| |COLLISION WITH VESSEL | |OPERATOR INEXPERIENCE | |CHANGING DIRECTION | |HBD NOT UNDER INFLUENCE |

| | | | | | | | |

| |COLLISION WITH FIXED OBJECT | |EXCESSIVE SPEED | |CHANGING SPEED | |HBD UNDER INFLUENCE |

| | | | | | | | |

| |COLLISION WITH FLOATING OBJECT | |MACHINERY FAILURE | |TOWING SKIER / TUBER | |HBD IMPAIRMENT UNKNOWN |

| | | | | | | | |

| |FALL OVERBOARD | |EQUIPMENT FAILURE | |TOWING SKIER - SKIER DOWN | |UNDER DRUG INFLUENCE |

| | | | | | | | |

| |FALL IN BOAT | |OFF-THROTTLE STEERING INABILITY| |TOWING ANOTHER VESSEL | |OTHER PHYSICAL IMPAIRMENT |

| | | | | | | | |

| |FIRE / EXPLOSION (fuel) | |IMPROPER LOADING | |BEING TOWED BY ANOTHER VESSEL | |IMPAIRMENT UNKNOWN |

| | | | | | | | |

| |FIRE / EXPLOSION (other than | |OVERLOADING | |DRIFTING | |NO OPERATOR |

| |fuel) | | | | | | |

| | | |HAZARDOUS WEATHER / WATER | |AT ANCHOR | | |

| |FLOODING / SWAMPING | | | | | | |

| | | |RESTRICTED VISION | |TIED TO DOCK | | |

| |GROUNDING | | | | | | |

| | | |IGNITION OF SPILLED FUEL / | |LAUNCHING | | |

| |SINKING | |VAPOR | | | | |

| | | | | |DOCKING / LEAVING DOCK | | |

| |STRUCK BY BOAT / PROPELLER | |IMPROPER ANCHORING | | | | |

| | | | | |SAILING | | |

| |SKIER MISHAP | |FAILURE TO VENT | | | | |

| | | | | |OTHER (specify)       | | |

| |OTHER:       | |UNKNOWN | | | | |

| | | | | | | | |

| | | |OTHER:       | | | | |

| | | | | | |SOBRIET| |

| | | | | | |Y | |

| | | | | | |TESTING| |

|VESSEL |HULL MATERIAL |PROPULSION |ENGINE |TYPE OF FUEL |

|TYPE | | | | |

| |

|REPORT NUMBER |INVESTIGATED BY (NAME, RANK) |ID NUMBER |REVIEWED BY |

| | | | |

|      |      |      |      |

DBW FORM VAR-1 (08/14)

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