Hunter e33 Operator's Manual page 31

For each question below, please provide answers
ACCIDENT DETAILS - YOUR BOAT -
INJURED PEOPLE RECEIVING OR IN NEED OF TREATMENT BEYOND FIRST AID
Report only injured people on, struck by, or being towed by your boat , receiving or in need of treatment beyond first aid.
Do not report injured people on, struck by, or being towed by another boat or no boat (e.g., swimmers, people on a dock).
If more than one injured person to report, attach additional copies of this page. If none , SKIP INJURED PEOPLE section.
INJURED PERSON
First:
Street:
City:
Phone: -
INJURY DETAILS
Injury caused when person
Struck the:
Was struck by a:
Was exposed to carbon monoxide poisoning
Received an electric shock
Other (describe):
Person was wearing lifejacket?
Person received treatment beyond first aid?
Person was admitted to a hospital?
ACCIDENT DETAILS - YOUR BOAT - DEATHS/DISAPPEARANCES
Only report deaths/disappearances of people on, struck by, or being towed by your boat.
If more than one death/disappearance to report, attach additional copies of this page.
If none , SKIP DEATHS/DISAPPEARANCES section.
PERSON WHO DIED/DISAPPEARED
First:
Street:
City:
Phone: -
DETAILS OF DEATH/DISAPPEARANCE
Injury caused when person
Struck the:
Was struck by a:
Was exposed to carbon monoxide poisoning
Received an electric shock
Other (describe):
U.S. Dept. of Homeland Security
-
(select all that apply):
(e.g., boat, water)
(e.g., boat, propeller)
Yes
Yes
Yes
-
(select all that apply):
(e.g., boat, water)
(e.g., boat, propeller)
U.S. Coast Guard CG-3865 (Rev 07-08)
IF APPLICABLE AND IF KNOWN,
MI: Last:
State:
Age:
Nature of most serious injury
Scrape/bruise
Cut
Sprain/strain
Concussion/brain injury
Spinal cord injury
Broken/fractured bone
No Body part of most serious injury
No
No
MI: Last:
State:
Age:
Nature of death/disappearance
Death - by drowning
Death - other likely cause (describe):
Disappeared and not yet recovered
Person was wearing lifejacket?
otherwise leave blank.
Zip:
(select one):
Dislocation
Internal organ injury
Amputation
Burn
Other (describe):
(e.g., head, hip,
Zip:
(select
Yes
-
knee):
-
one):
No
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