Albemarle 41 CONVERTIBLE, Руководство пользователя, Страница: 128 / 138

410 Convertible
128
If more than 3 fatalities and/or injuries, attach additional form(s)
WAS VICTIM?
[ ] Swimmer
[ ] Non Swimmer
DATE OF
BIRTH
ADDRESS
NAME
DEATH CAUSED BY
[ ] Drowning
[ ] Other
[ ] DISAPPEARANCE
WAS PFD WORN?
[ ] Yes [ ] No
What Type?
WAS VICTIM?
[ ] Swimmer
[ ] Non Swimmer
DATE OF
BIRTH
ADDRESS
NAME
DEATH CAUSED BY
[ ] Drowning
[ ] Other
WAS PFD WORN?
[ ] Yes [ ] No
What Type?
WAS VICTIM?
[ ] Swimmer
[ ] Non Swimmer
DATE OF
BIRTH
ADDRESS
NAME
DEATH CAUSED BY
[ ] Drowning
[ ] Other
WAS PFD WORN?
[ ] Yes [ ] No
What Type?
[ ] DISAPPEARANCE
[ ] DISAPPEARANCE
ADDRESS
NAME
ADDRESS
NAME
ADDRESS
NAME
NATURE OF INJURY DATE OF
BIRTH
DATE OF
BIRTH
DATE OF
BIRTH
NATURE OF INJURY
NATURE OF INJURY
MEDICAL TREATMENT
MEDICAL TREATMENT
MEDICAL TREATMENT
DESCRIBE WHAT HAPPENED (Sequence of events. Include Failure of Equipment. If diagram is needed, attach separately. Continue on additional sheets
if necessary. Include any information regarding the involvement of alcohol and/or drugs in causing or contributing to the accident. Include any descriptive
information about the use of PFD’s.)
INJURED
VESSEL NO. 2 (if more than 2 vessels, attach additional form (s)
DECEASED
ACCIDENT DESCRIPTION
Name of Owner
Telephone Number
Name of Operator
Address
Address
Address
Name
Name
Name
Address
Address
Boat Name
Boat Number
Telephone Number
Telephone Number
Telephone Number
Telephone Number
Date Submitted
Date Received
Reviewed By
Address
SIGNATURE
QUALIFICATION (Check One)
[ ] Operator [ ] Owner [ ] Investigator [ ] Other
Causes based on (check one)
[ ] This report [ ] Investigation and this report
[ ] Investigation [ ] Could not be determined
Primary Cause of Accident
Secondary Cause of Accident
Name of Reviewing Office
(do not use) - FOR REPORTING AUTHORITY REVIEW (use agency date stamp)
WITNESSES
WITNESSES
BOATING ACCIDENT REPORT