PENNSYLVANIA BOATING ACCIDENT REPORT

PENNSYLVANIA FISH & BOAT COMMISSION

Instructions:

State Law requires this report to be completed and filed within 48 hours by the operator of the boat involved in an accident resulting in death, disappearance

or injury requiring medical treatment beyond first aid. Accidents involving aggregate property damage exceeding $2,000 must be reported within 10 days. If the operator is

unable, the owner of every vessel involved must report the accident. All reports are confidential and for the use of the Commission for boating safety purposes only. Reports

must be sent to:

Pennsylvania Fish & Boat Commission, Boating Accident Report, P.O. Box 67000, Harrisburg, PA 17106-7000.

PFBC-260 (5/12)

DATE OF ACCIDENT (M/D/Y)

TIME OF ACCIDENT

COUNTY

BODY OF WATER

LOCATION ON WATER



INJURED

# DEAD/MISSING

TOTAL

$ DAMAGE

LAW ENFORCEMENT ON ACCIDENT SCENE? IF YES, LIST AGENCY NAME

WEATHER (CHECK ALL THAT APPLY) WATER CONDITIONS (CHECK ONE)

WIND CONDITIONS (CHECK ONE)

TEMPERATURE

WATER AIR

VISIBILITY (CHECK ONE) STRONG CURRENT?

 GOOD

 FAIR

 POOR

 YES  NO

 CLEAR

 CLOUDY

 FOG

 RAIN

 SNOW

 HAZY

 CALM (waves less than 6″)

 CHOPPY (waves 6″ - 2′)

 ROUGH (waves 2 - 6′)

 VERY ROUGH (waves >6′)

 NONE

 LIGHT (0 - 6 mph)

 MODERATE (7 - 14 mph)

 STRONG (15 - 25 mph)

 STORM (over 25 mph)

TYPE OF ACCIDENT (CHECK ALL THAT APPLY)

 CAPSIZING

 COLLISION WITH VESSEL

 COLLISION WITH FIXED OBJECT

 COLLISION WITH FLOATING OBJECT

 FALL OVERBOARD

 FALL IN BOAT

 OTHER

 FIRE / EXPLOSION (fuel)

 FIRE / EXPLOSION (other than fuel)

 FLOODING / SWAMPING

 SINKING

 STRUCK BY BOAT / PROPELLER

 SKIER MISHAP

CAUSE OF ACCIDENT (CHECK ALL THAT APPLY)

 IMPROPER LOOKOUT / INATTENTION

 OPERATOR INEXPERIENCE

 EXCESSIVE SPEED

 MACHINERY FAILURE

 EQUIPMENT FAILURE

 IMPROPER LOADING

 OVERLOADING

 HAZARDOUS WEATHER / WATER

 RESTRICTED VISION

 IGNITION OF SPILLED FUEL / VAPOR

 IMPROPER ANCHORING

 ALCOHOL USE

 FAILURE TO VENT

 OTHER

VICTIM OR WITNESS INFORMATION

 YES

 NO

LIFE JACKET

WORN?

 YES

 NO

 YES

 NO

 YES

 NO

 INJURED

 DEAD

 WITNESS ONLY

STATUS (CHECK ONE)

 INJURED

 DEAD

 WITNESS ONLY

 INJURED

 DEAD

 WITNESS ONLY

 INJURED

 DEAD

 WITNESS ONLY

DATE OF

BIRTH

NAME & ADDRESS

INJURY DESCRIPTION

DESCRIBE WHAT HAPPENED

THIS CONFIDENTIAL REPORT IS USED IN RESEARCH FOR THE PREVENTION OF ACCIDENTS

MEDICAL

TREATMENT?

 YES

 NO

 YES

 NO

 YES

 NO

 YES

 NO

(Describe sequence of events. Include failure of equipment. If diagram is needed, attach separately. Continue on additional sheets if necessary. Include any information regarding the involvement of alcohol and/or

drugs in causing or contributing to the accident. Include any descriptive information about the use of life jackets.)

PFBC-260 (5/12)

INFORMATION: OPERATOR #1

THIS CONFIDENTIAL REPORT IS USED IN RESEARCH FOR THE PREVENTION OF ACCIDENTS

PENNSYLVANIA BOATING ACCIDENT REPORT

PENNSYLVANIA FISH & BOAT COMMISSION

Signature of person completing this report

Name of person completing this report

INFORMATION: VESSEL #1

DATE OF BIRTH

OPERATOR NAME AND ADDRESS

IS OWNER DIFFERENT THAN OPERATOR?

OWNER NAME AND ADDRESS

 YES  NO

OPERATOR EXPERIENCE (CHECK ONE)

OPERATOR EDUCATION (CHECK ONE)

 NONE

 STATE COURSE

 USCG AUXILIARY

 US POWER SQUADRONS

 INTERNET

 OTHER

 0 TO 10 HOURS

 OVER 10,

UP TO 100 HOURS

 OVER 100,

UP TO 500 HOURS

 OVER 500 HOURS

INJURED

DEAD

THIS

VESSEL

ONLY

ESTIMATED $ DAMAGE RENTED BOAT?

 YES  NO

OF PERSONS ONBOARD

OF PERSONS TOWED

REGISTRATION NUMBER (PA OR DOC

) MFR. HULL ID

BOAT NAME

LENGTH

BOAT MANUFACTURER BOAT MODEL YEAR BUILT TYPE OF FUEL

OF ENGINES HORSEPOWER

ACTIVITY FIRE EXTINQUISHER ONBOARD? FIRE EXTINQUISHER USED?

 YES  NO

OF LIFE JACKETS ONBOARD LIFE JACKETS WORN?

 YES  NO 

RECREATIONAL



COMMERCIAL



OTHER

 OPEN MOTORBOAT

 CABIN MOTORBOAT

 PERSONAL WATERCRAFT

 HOUSEBOAT

 SAILBOAT

(aux. engine)

 SAILBOAT (sail only)

 CANOE

 KAYAK

 PONTOON

 AIR BOAT

 RAFT

 ROWBOAT

 OTHER

(specify)

TYPE OF BOAT (CHECK ONE)

INFORMATION: OPERATOR #2

 WOOD

 ALUMINUM

 FIBERGLASS

 PLASTIC

 RUBBER / VINYL

 STEEL

 OTHER

(specify)

HULL MATERIAL (CHECK ONE)

 OUTBOARD

 INBOARD

 INBOARD / OUTBOARD

 JET

 SAIL ONLY

 PADDLE / OARS

 OTHER

(specify)

PROPULSION (CHECK ONE)

 CRUISING

 CHANGING DIRECTION

 CHANGING SPEED

 TOWING SKIER / TUBER

 TOWING SKIER - SKIER DOWN

 TOWING ANOTHER VESSEL

 BEING TOWED BY ANOTHER VESSEL

OPERATION AT TIME OF ACCIDENT (CHECK ONE)

 DRIFTING

 AT ANCHOR

 TIED TO DOCK

 LAUNCHING

 DOCKING / LEAVING DOCK

 SAILING

 OTHER

(specify)

SPEED

MPH

INFORMATION: VESSEL #2

OPERATOR NAME AND ADDRESS

IS OWNER DIFFERENT THAN OPERATOR?

OWNER NAME AND ADDRESS

 YES  NO

INJURED

DEAD

THIS

VESSEL

ONLY

ESTIMATED $ DAMAGE RENTED BOAT?

 YES  NO

OF PERSONS ONBOARD

OF PERSONS TOWED

REGISTRATION NUMBER (PA OR DOC

) MFR. HULL ID

BOAT NAME

LENGTH

BOAT MANUFACTURER BOAT MODEL YEAR BUILT TYPE OF FUEL

OF ENGINES HORSEPOWER

ACTIVITY FIRE EXTINQUISHER ONBOARD? FIRE EXTINQUISHER USED?

 YES  NO

OF LIFE JACKETS ONBOARD LIFE JACKETS WORN?

 YES  NO 

RECREATIONAL



COMMERCIAL



OTHER

 OPEN MOTORBOAT

 CABIN MOTORBOAT

 PERSONAL WATERCRAFT

 HOUSEBOAT

 SAILBOAT

(aux. engine)

 SAILBOAT (sail only)

 CANOE

 KAYAK

 PONTOON

 AIR BOAT

 RAFT

 ROWBOAT

 OTHER

(specify)

TYPE OF BOAT (CHECK ONE)

 WOOD

 ALUMINUM

 FIBERGLASS

 PLASTIC

 RUBBER / VINYL

 STEEL

 OTHER

(specify)

HULL MATERIAL (CHECK ONE)

 OUTBOARD

 INBOARD

 INBOARD / OUTBOARD

 JET

 SAIL ONLY

 PADDLE / OARS

 OTHER

(specify)

PROPULSION (CHECK ONE)

 CRUISING

 CHANGING DIRECTION

 CHANGING SPEED

 TOWING SKIER / TUBER

 TOWING SKIER - SKIER DOWN

 TOWING ANOTHER VESSEL

 BEING TOWED BY ANOTHER VESSEL

OPERATION AT TIME OF ACCIDENT (CHECK ONE)

 DRIFTING

 AT ANCHOR

 TIED TO DOCK

 LAUNCHING

 DOCKING / LEAVING DOCK

 SAILING

 OTHER

(specify)

SPEED

MPH

QUALIFICATION OF PERSON COMPLETING REPORT

 OPERATOR  OWNER  OTHER

(specify)