Accident Report Form
Please return this form within 24-hours of an event involving injuries, deaths, and/or damage to a Club boat or by a Club boat. Member Programs: Skipper and each crew are to complete their own incident form. Lessons / Racing Programs / Clinics: Instructor and each injured crew are to complete their own reports.
Full Name
*
Position on board
*
Skipper
Crew
Other
PHONE
*
Format: (000) 000-0000.
EMAIL
*
example@example.com
Address: Street, Apt/Suite, City, State, Zip
*
Accident Date:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Accident Time
*
Hour Minutes
AM
PM
AM/PM Option
Location of the accident. Please provide coordinates if available.
*
Boat/s Involved in the Accident
Which Club boat were you on when the accident occurred?
*
Please Select
Red Inflatable Zodiac
J/80 - Fearful Symmetry
J/80 - Jammy Dodger
J/80 - Namaste
J/80 - Raven
J/80 - Stellar J
J/80 - Taj Mahal
J/80 - Underdog
J/80 - Manic
C&C 27 - Blew Moon
C&C 27 - Makai
C&C 27 - PenDragon
Ericson 26 - Leif
Beneteau 31 - Moshi
Hanse 342 - Silver Girl
J/105 - Bluelight
J/105 - Counterpoint
J/105 - Creative
J/105 - Mazu
J/105 - Jaded
J/105 - Moonglow
J/105 - Paladin
J/105 - Puff
J/35c - Astraea
J/35c - La Dolce Vita
J/35c - No Name (Irene)
Beneteau 40 Cemre
Jeanneau 40 - Taureau
Jeanneau 409 - Sea Dancer
Jeanneau 45 - Colibri
Dehler 38 - Allons-y
Excess 11 - Why Knot
Was another boat involved in the accident? If yes, please provide their information in the field below.
*
Yes
No
Boats involved in the accident. Include the full name of the owner/skipper, phone, email, boat make/model & name. Description of damage to this boat.
Operations at the time of the incident:
*
Under sail
At anchor
Under motor
Tied to dock
Changing Direction
Docking/ Departing from Dock
Changing Speed
Drifting
Other
Causes of the incident:
*
Improper crew loading
Improper Lookout/inattention
Hazardous Weather/Water
Operator inexperience
Improper anchoring
Overloading
Excessive Speed
Restricted vision
Machinery Failure
Equipment Failure
Alcohol / Drug Use
Other
Description of the event before, during, and after. Include things such as wind speed & direction, visibility, direction of boats (if collision occurred), speed of the boat, point of sail, grounding type (hard/soft), location, and details about the event.
*
Please upload photos of damages or broken parts on the vessel.
Did the event occur during one of the following?
*
Member Boat Reservation
Sailing Lesson
Racing Program
Corporate Team Building Event
Club Clinic
On the Job (employees only)
Other
Injuries or Deaths Onboard
How many people were injured on board?
*
Were there any deaths on board?
*
Yes
No
Unknown
Add the information below for each person who was injured/deceased on board. If there were more than 3 people, please send a follow up with the remaining information.
Was first aid administered?
*
Yes
No
I don't know
Was emergency response called?
*
Yes
No
I don't know
Post-Accident
What recommendations do you have to prevent incidents of this type in the future?
*
The information provided on this report is true to the best of my knowledge.
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: