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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