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Appendix E Boating Accident Report
E-6
For each question below, please provide answers IF APPLICABLE AND IF KNOWN, otherwise leave blank.
YOUR BOAT OPERATOR
NAME/ADDRESS
First Name MI Last Name
Street
City State Zip
AGE/GENDER/PHONE
Date of Birth
PPGG\\\\
Age
Gender Male Female
Phone
YOUR BOAT OWNER
If same as \RXU boat RSHUDWRU SKIP rest of YOUR BOAT OWNER section.
NAME/ADDRESS/PHONE
First Name MI Last Name
Street
City State Zip Phone
PERSON SUBMITTING THIS REPORT
If same as \RXU boat RSHUDWRU OR RZQHU , SKIP rest of PERSON SUBMITTING THIS REPORT section.
NAME/ADDRESS/PHONE/ROLE
First Name MI Last Name
Street
City State Zip Phone
I was a(n)
VHOHFWRQH
Other person on board WKLV boat
Accident witness QRW on board WKLV boat
Other GHVFULEH
SIGNATURE OF PERSON SUBMITTING THIS REPORT
Your signature Date
PPGG\\\\
An Agency may not conduct or sponsor and a person is not required to respond to an information collection, unless it
displays a currently valid OMB Control Number.
The Coast Guard estimates that the average burden for this report form is 30 minutes. You may submit any comments
concerning the accuracy of this burden estimate or any suggestions for reducing the burden to: Commandant (CG-
%6; 2 ), U.S. Coast Guard, Washington, DC 20593-0001 or Office of Management and Budget, Paperwork Reduction
Project (1625-0003), Washington, DC 20503.
CG-3865 ( /1 ) Page 6 of 6
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