RECREATIONAL BOAT ACCIDENT REPORT
ADDITIONAL FATALITY
AGENCY CASE #
BARD #
BOAT #
Person who died or disappeared
Same information as: (e.g., operator or passenger/witness #1)
Deceased persons information
Last:
First: MI:
S
treet:
City:
S
tate:
Zip: Phone:
D
ate of Birth
Age: Male Female
Alcohol use apparent Yes No BAC Drug use apparent Yes No Type
Fishing Tubing
Hunting Water Skiing
Scuba Diving / Snorkeling
Swimming
Other (specify)
None
Was person wearing a lifejacket? Yes No
Life Jacket Type
L
ife Jacket Use Information:
Worn Inflatable
Inherently buoyant Not worn but used
Prior to accident Not worn and not used
As a result of accident Unknown
Injury caused when person (select all that apply):
Struck the:
(e.g., boat, water)
Was struck by a:
(e.g., boat, propeller)
Was exposed to carbon monoxide poisoning
Received an electric shock
Other (describe):
Nature of death/disappearance (select one):
Death – by drowning
Death – other likely cause (describe):
Disappeared and not yet recovered? Yes No
The deceased or missing person was (select one):
Boat operator/owner Passenger on the boat
Person being towed by the boat
