Accident Report Form

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*

SkipperCrewOther
PHONE*
EMAIL*
example@example.com
Address: Street, Apt/Suite, City, State, Zip*
Accident Date:*

MonthDayYear
Date
Accident Time*

Hour Minutes

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?*
Was another boat involved in the accident? If yes, please provide their information in the field below.*

YesNo
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 sailAt anchorUnder motorTied to dockChanging DirectionDocking/ Departing from DockChanging SpeedDriftingOther
Causes of the incident:*

Improper crew loadingImproper Lookout/inattentionHazardous Weather/WaterOperator inexperienceImproper anchoringOverloadingExcessive SpeedRestricted visionMachinery FailureEquipment FailureAlcohol / Drug UseOther
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 ReservationSailing LessonRacing ProgramCorporate Team Building EventClub ClinicOn the Job (employees only)Other
Injuries or Deaths Onboard
How many people were injured on board?*
Were there any deaths on board?*

YesNoUnknown
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?*

YesNoI don't know
Was emergency response called?*

YesNoI 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. *

Clear
Date*

MonthDayYear
Date
Should be Empty: