Fillable RECREATIONAL BOATING ACCIDENT REPORT (State of Idaho)

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RECREATIONAL BOATING ACCIDENT REPORT (State of Idaho)

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RECREATIONAL BOATING ACCIDENT REPORT
IDAHO DEPARTMENT OF PARKS AND RECREATION
PO BOX 83720
BOISE, ID 83720-0065
Agency Case #
BARD #
REPORT REQUIREMENTS
The operator of any vessel involved in a collision, accident or other casualty resulting in death, injury or property
damage in excess of $1,500 must file a Boating Accident Report (67-7027, Idaho Code). Reports in cases of death,
incapacitating injury or disappearance must be submitted within 48 hours. Reports in other cases must be
submitted within 10 days. All reports shall be submitted to the sheriff of the county in which the accident occurred,
and a copy shall be readily transmitted by the sheriff’s department to the State Boating Law Enforcement
Coordinator, Idaho Department of Parks and Recreation.
Report required because (select all that apply):
□ At least one person in this accident died.
□ At least one injured person in this accident (required or was in need of treatment beyond first aid).
□ At least one person in this accident disappeared and has not yet been recovered.
□ All boat and other property damage (e.g., fishing/hunting gear) related to this accident totaled (or likely
totaled) $1,500 or more.
□ Boats in this accident is (or likely is) a total loss.
ACCIDENT SUMMARY
When
Date: MM/DD/YY Time: am pm (select one)
Where
Body of water name:
L
ocation (on water) description:
N
earest city/town:
County: State:
Accident Description:
1
RECREATIONAL BOAT ACCIDENT REPORT
Accident Diagram
Diagram the position and direction of travel of boat(s) involved
Before Impact
At Impact
Sequence of Events
Breifly describe the sequence of events
Contributing Factors
Indicate factors on each boat which may have contributed to this accident (select all that apply for each boat):
B1 B2
Alcohol use
Careless/reckless
Operation
Congested waters
Dam/lock
Drug use
Equipment failure
Excessive speed
Failure to vent
Hazardous waters
Hull failure
Ignition of fuel or
Vapor
Machinery failure
B1 B2
Operator inattention
Improper anchoring
Improper loading
Lack of/improper boat
lights
Operator inexperience
Overloading
Passenger/skier
Behavior
Restricted vision
Navigation rules
Violation
Sharp turn
B1 B2
People on
gunwhale, bow or
transom
Starting in gear
Force of wake /
wave
Heavy weather
Improper lookout
Off throttle
steering Loss
Navigation aids
Missing
Navigation aid
not performing
B1 B2
Failure to yield
Lack of /
improper ski
observer
Other
(describe):
B1
B2
Unknown
Language
barrier
2
RECREATIONAL BOAT ACCIDENT REPORT
Machinery Equipment Failure
Failure of the following machinery/equipment that contributed to this accident (select all that apply for each
boat):
B1 B2
Auxiliary equipment
Communication
equipment
Fire extinguisher
Sail/mast
Seats
B1 B2
Sound
equipment
(e.g., horn,
whistle)
Visual distress
signals
B1 B2
Outboard
navigation aids
Electrical system
Engine
Fuel system
Shift
B1 B2
Steering
Throttle
Ventilation
Radio
Onboard lights
Type of Accident
Number by order of occurrence
B1 B2
Grounding
Capsizing
Flooding/swamping
Sinking
Fire/explosion – fuel
Fire/explosion – non-fuel
Mishap of skier, tuber,
wake boarder, etc.
Collision with recreation boat
Collision with commercial
boat
B1 B2
Collision with fixed object
Collision with floating
object
Person fell overboard
Person fell on/within boat
Person struck by boat
Person struck by
propulsion unit
Collision with submerged
object
Starting engine
B1 B2
Carbon monoxide exposure
Person electrocuted
Fall on boat
Person ejected from boat
Sudden medical condition
Person left boat voluntarily
Other (describe):
B1
B2
Unknown
Accident Details – External Conditions
Weather (check all
applicable):
Clear
Cloudy
Foggy
Raining
Snowing
Hazy
Other (describe):
Time of day:
Day
Night
Visibility:
Good
Fair
Poor
Wind:
0 mph (none)
Over 0, up to 12 mph
(light)
Over 12, up to 25 mph
(moderate)
Over 25, up to 55
mph (strong)
Over 55 mph (strong)
Approximate air temperature: °F
Approximate water temperature:
°
F
Water Conditions
Overall water conditions (select one):
Up to 6 inch waves (calm)
Over 6 inch, up to 2 foot waves (choppy)
Over 2 foot, up to 6 foot waves (rough)
Over 6 foot waves (very rough)
Other water conditions:
Strong current? Yes No
Hazardous waters? Yes No
Congested waters? Yes No
3
RECREATIONAL BOAT ACCIDENT REPORT
BOAT #1
Owner Information
Last name: First: MI:
Street:
City:
State: Zip: Phone number:
Boat Information
Registration number: State (where registered):
Hull number (HIN):
Boat name:
Manufacturer:
Model: Year:
Length: ft. In. Rented: Yes No
Type of Boat
(select one):
Cabin motorboat
Open motorboat
Auxiliary sail
Pontoon boat
Inflatable
House boat
Sail (only)
Kayak
Canoe
Rowboat
Airboat
Jet Boat
Personal watercraft (PWC)
Unknown
Other (specify):
Propulsion (select all that apply):
Propeller
Water jet
Air thrust
Manual
Sail
Other (describe):
Hull Material
Fiberglass Steel Rigid Hull Inflatable
Aluminum Rubber/vinyl/canvas Kevlar
Wood Plastic Other (Specify):
Engine
Number of engines:
Manufacturer:
Total horsepower:
Engine type
(select one):
Outboard
Inboard
Stern drive (I/O)
None
Fuel type
(select all that apply):
Gasoline
Diesel
Electric
Safety Measures
Instructions in boat safety (select one): Received PWC rental education? Yes No
None US Power Squadron
State course Internet Course Unknown
US Coast Guard Auxiliary American Red Cross Other (describe):
Number of lifejackets on board:
Number of lifejackets used:
Number of fire extinguishers on board:
Number of fire extinguishers used:
Type of fire extinguishers (e.g., B-I, B-II):
Damage to the boat
Briefly summarize any damage to the boat:
Estimated amount of damage to the boat:
Was the boat a total loss? Yes No
Insurance Company:
Briefly summarize any damage to other property (not the boat) (e.g., fishing gear):
Estimated amount of damage to other property:
4
RECREATIONAL BOAT ACCIDENT REPORT
BOAT #1 continued
Point of impact
(indicate all that
apply):
11 – Below water line
12 – Lower Unit
13 – Windsheild
14 – Burned
15 – Sunk
16 – Injuries – No
Damage
Positions
Indicate the positions in boat for Operator (O),
Passenger (#), Seated (S), Stand (A), and other
(N).
Post acceleration to boat:
R – Remains aboard
F – Fall
E – Ejected
L – Leaves boat voluntarily
T – Trapped in overturned boat
Examples below:
OAR
– Operator, stand, remains aboard
2SF – Passenger #2, seated, fall overboard
Operator/Passenger Activities
Operator/Passenger activities on the boat at time of accident:
Activities were (select one):
Recreational
Commercial
Number of people on board:
Number of people being towed:
Activity at Time of Accident:
Fishing Racing
Fishing tournament White water sports
Hunting Fueling
Swimming/Diving Starting engine
Making repairs Non-Recreational
Water skiing/Tubing Scuba Diving/Snorkeling
Other (list): Relaxing
Operation at Time of Accident:
Cruising
Changing direction
Changing speed
Drifting
Towing another
Vessel
Being towed
Rowing/paddling
Sailing
Launching
Docking/undocking
At anchor
Tied to
dock/mooring
Other (list):
Estimated Speed: Drifting Under 10 mph 10 – 20 mph Over 20 mph Over 40 mph None
Key People/Operator
Name/address boat operator Same as the owner
Last: First: MI:
Street:
City:
State:
Zip: Phone:
Male Female DOB: DL#: State:
Was life jacket worn? Yes No If yes, what type: Before As a result of
Was operator injured beyond first aid? Yes No Fatal? Yes No
Operator report status (select one):
No operator Complete Incomplete None
Was a boating citation issued? Yes No If yes, indicate violation and code section :
Was alcohol involved? Yes No OUI arrest? Yes No BAC level:
Operators experience: 0 to 10 hours Over 10, up to 100 hours Over 100, up to 500 Over 500 hours
5
RECREATIONAL BOAT ACCIDENT REPORT
BOAT #1 continued
Other key people #1
Other key person was (select all that apply): Passenger on boat Person being towed by boat Witness
Name/address of other key person
Last:
First: MI:
Street:
City:
State:
Zip: Phone:
Male Female DOB: DL#: State:
Was life jacket worn? Yes No If yes, what type: Before As a result of
Was this person injured beyond first aid? Yes No Fatal? Yes No
Other key people #2
Other key person was (select all that apply): Passenger on boat Person being towed by boat Witness
Name/address of other key person
Last:
First: MI:
Street:
City:
State:
Zip: Phone:
Male Female DOB: DL#: State:
Was life jacket worn? Yes No If yes, what type: Before As a result of
Was this person injured beyond first aid? Yes No Fatal? Yes No
Other key people #3
Other key person was (select all that apply): Passenger on boat Person being towed by boat Witness
Name/address of other key person
Last:
First: MI:
Street:
City:
State:
Zip: Phone:
Male Female DOB: DL#: State:
Was life jacket worn? Yes No If yes, what type: Before As a result of
Was this person injured beyond first aid? Yes No Fatal? Yes No
6
RECREATIONAL BOAT ACCIDENT REPORT
BOAT #1 continued
Accident Details – Injured people receiving or in need of treatment beyond first aid
Injured person information
Same information as:
(e.g., operator or passenger/witness #1)
Last:
First: MI:
Street:
City:
State:
Zip: Phone:
Date 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
Describe Injury:
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)
Body part of most serious injury (e.g., head, hip):
Secondary (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):
7
RECREATIONAL BOAT ACCIDENT REPORT
BOAT #1 continued
Person who died or disappeared
Same information as: (e.g., operator or passenger/witness #1)
Deceased persons information
Last:
First: MI:
Street:
City:
State:
Zip: Phone:
Date of Birth
Age: Male Female
Alcohol use apparent Yes No BAC Drug use apparent Yes No Type
Victim Activity:
Fishing Tubing
Hunting Water Skiing
Scuba Diving / Snorkeling
Swimming
Other (specify)
None
Was person wearing a lifejacket? Yes No
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):
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
Person submitting this report
Reporting officer/investigators information
Last:
First: MI:
Agency:
Street:
City:
State:
Zip: Phone:
Email:
Signature:
Date:
State Reporting Authority
Signature of reviewing official: Date:
Causes based on: This report Investigation Investigation and this report Could not be determined
Primary cause of accident:
State reporting authority:
Date:
8
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RECREATIONAL BOATING ACCIDENT REPORT (State of Idaho)

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Completed 20 July 2020

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