RECREATIONAL BOAT ACCIDENT REPORT
ADDITIONAL INJURY INVOLVED IN THE ACCIDENT
Accident Details – Injured people receiving or in need of treatment beyond first aid
Injured person information
Last:
First: MI:
S
treet:
City:
S
tate:
Zip: Phone:
D
ate of Birth
Age: Was injured person wearing a lifejacket? Yes No
Person received treatment beyond first aid: Yes No Person was admitted to a hospital: Yes No
Primary Injury (check one)
Unknown Head Injury
Amputation Hypothermia
Back Injury Internal Injuries
Broken Bone(s) Laceration
Burns Neck Injury
Carbon Monoxide Poisoning Shock
Contusion Spinal Injury
Dislocation Sprain/strain
Electrocution Teeth
Other (describe)
B
ody part of most serious injury (e.g., head, hip):
Secondary Injury (Check all that apply):
Unknown Head Injury
Amputation Hypothermia
Back Injury Internal Injuries
Broken Bone(s) Laceration
Burns Neck Injury
Carbon Monoxide Poisoning Shock
Contusion Spinal Injury
Dislocation Sprain/strain
Electrocution Teeth
Other (describe)
The injured person was (select one):
Boat operator/owner Passenger on the boat
Person being towed by the boat
Alcohol use apparent Yes No BAC
Life Jacket Type
Life 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):
1
