CG-2692B Report of Required Chemical Drug and Alcohol Testing Fol

DEPARTMENT OF HOMELAND SECURITY

OMB No. 1625-0001

U.S. Coast Guard
Expires: xx/xx/xxxx
REPORT OF REQUIRED CHEMICAL DRUG AND ALCOHOL TESTING FOLLOWING A
SERIOUS MARINE INCIDENT
(See Instructions on reverse)

SECTION I—VESSEL INFORMATION
1. Name of vessel

2. Official Number

3. Call Sign

4. Nationality

5. Vessel Type (Freight, Towing, Fishing, MODU, etc.)

6. Length

7. Gross Tons

8. Year Built

9. Operating Company

10. Master or Person in Charge

Name:

Name:

Address:

Address:

Telephone Number:

Telephone Number:

SECTION II—INCIDENT INFORMATION
11. Type of Serious Marine Incident (Check Appropriate Box(es). (See Instructions on Reverse)

a.

Death (Append to Form CG-2692)

e.

Loss of uninspected, self-propelled vessel of over
100 gross tons (Append to Form CG-2692)

b.

Injury requiring medical treatment
(Append to Form CG-2692)

f.

Discharge of oil of 10,000 gallons or more into U.S. waters

c.

Property damage in excess of $100,000
(Append to Form CG-2692)

g.

Discharge of a reportable quantity of hazardous
substance into U.S. waters

d.

Loss of inspected vessel (Append to
Form CG-2692)

h.

Release of a reportable quantity of hazardous substance
into U.S. environment

12. Date of Incident

13. Time (local) of Incident

14. Location of Incident (Latitude and Longitude or River and Milepost)

SECTION III—PERSONNEL / TESTING INFORMATION

NO

YES

NO

__________________________
__________________________
__________________________
__________________________
__________________________
17. SAMHSA Accredited Laboratory Conducting Chemical Drug Tests

________
________
18. Laboratory conducting blood alcohol test(s) or individual conducting saliva or
breath alcohol test(s)
Name:

Address:

Address:

Telephone Number:

16d.
Alcohol
Test
Results

________
________
________

Name:

19. Person Making This Report (Please Print)

Breath

YES

Blood

(Check Appropriate Box(es))
USCG
USCG
License
MMD
Neither

16. Drug and Alcohol Testing (See Instructions on reverse)
16a. Drug Test Urine
16b. Alcohol Test
16c. Alcohol Test
Specimen provided
Specimen provided
Specimen Source
within 32 hours?
within 2 hours?
Saliva

15. Personnel Directly Involved In Serious Marine Incident
15a. Name (Last, First, Middle Initial)
15b. Licensing/Certification

Telephone Number:
20. Signature

21. Date

Name:
Address:
Telephone Number:
22. Remarks (See Instructions on Reverse)

CG-2692B (11/12)

Title:

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INSTRUCTIONS FOR COMPLETION OF FORM CG-2692B
REPORT OF REQUIRED CHEMICAL DRUG AND ALCOHOL TESTING
FOLLOWING A SERIOUS MARINE INCIDENT
NOTE: When this form is being submitted along with a REPORT OF MARINE ACCIDENT, INJURY OR DEATH
(Form CG-2692), Blocks 3-10 and Blocks 12-14 on Form CG-2692B need not be completed.
An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number.
The Coast Guard estimates that the average burden for this report is .5 hours. You may submit any comments concerning the accuracy of this burden
estimate or any suggestions for reducing the burden to: Commandant (G-MOA), U.S. Cost Guard, 2100 2nd St, SW, Washington D.C. 20593-0001 or Office
of Management and Budget, Paperwork Reduction Project (1625-0001), Washington, DC 20503.

WHEN TO USE THIS FORM
1. This form satisfies the requirements in the Code of Federal
Regulations for written reports of chemical drug and alcohol testing
of individuals directly involved in serious marine incidents. Alcohol
tests are to be conducted not later than 2 hours (unless there are
casualty directly related safety concerns) and drug test specimens
collected not later than 32 hours after a Serious Marine Incident.
Public vessels and recreational vessels are excepted from these
reporting requirements.
SERIOUS MARINE INCIDENTS
2. The term "serious marine incident" includes the following events
involving a vessel in commercial service:
A. Any marine casualty or accident that occurs upon the
navigable waters of the U.S., its territories or possessions, or
that involves a U.S. vessel anywhere, and that results in any of
the following:
1. One or more deaths;
2. Any injury to a crewmember, passenger, or other person
which requires professional medical treatment beyond first aid;
and, in the case of a person employed on board a vessel in
commercial service, which renders the individual unfit to perform
routine vessel duties;
3. Damage to property, as defined in 46 CFR 4.05-1(f), in
excess of $100,000;
4. Actual or constructive total loss of any vessel subject to
inspection under 46 U.S.C. 3301; or
5. Actual or constructive total loss of any self-propelled vessel,
not subject to inspection under 46 U.S.C. 3301, of 100
gross tons or more.
B. A discharge of oil of 10,000 gallons or more into the
navigable waters of the United States, as defined in 33 U.S.C.
1321, whether or not resulting from a marine casualty.
C. A discharge of a reportable quantity of a hazardous substance
Into the navigable waters of the United States, whether or not
resulting from a marine casualty.
D. A release of a reportable quantity of a hazardous substance
Into the environment of the United States, whether or not
resulting from a marine casualty.

INDIVIDUAL DIRECTLY INVOLVED IN A SERIOUS
MARINE INCIDENT
3. Term "individual directly involved in a serious marine incident"
is an individual whose order, action or failure to act is determined
to be, or cannot be ruled out as, a causative factor in the events
leading to or causing a serious marine incident.
COMPLETION OF THIS FORM
4. This form should be filled out as completely and accurately as
possible. Please type or print clearly. Fill in all blanks that apply to
the kind of incident that has occurred. If a question is not applicable,
the abbreviation "NA" should be entered in that space. If an answer
Is unknown and cannot be obtained, the abbreviation "UNK" should
be entered in that space. If "NONE" is the correct response, then
enter it in that space.
5. If more than 5 personnel are directly involved in the Serious
Marine Incident an additional CG-2692B should be completed.
6. When this form has been completed, deliver or mail it as soon as
practicable to the Coast Guard Marine Safety or Marine Inspection
Office nearest to the location of the incident or, if at sea, nearest to
the port of first arrival.
7. Upon receipt of a report of chemical test results, the marine
employer shall submit a copy of the test results for each person
listed in block 15(a) of this form to the Coast Guard Officer in
Charge, Marine Inspection where the CG-2692B was submitted.
(Ref. 46 CFR 4.06-60(d)).
8. Amplifying information for completing the form:
A. Block 11—"TYPE OF SERIOUS MARINE INCIDENT"
Check each appropriate box. If box a, b, c, d, or e is checked,
or append this form to the required form CG-2692, "REPORT
OF MARINE ACCIDENT, INJURY OR DEATH", and submit
both forms as indicated in 5. above.
B. Block 16d—"ALCOHOL TEST RESULTS"
When the alcohol test results are available, the alcohol
concentration shall be expressed numerically in percent by
weight (i.e., .04, .10 etc…).
C. Block 22—"REMARKS" Describe the duties of each
individual listed in 15a, at the time of incident (i.e., master,
pilot, chief engineer...). If an individual refuses to provide
the required specimens, if specimens are not timely obtained,
or not obtained, describe the circumstances completely.

NOTICE: The information collected on this form is routinely available for public inspection. It is needed by the Coast Guard to carry out its
responsibility to investigate marine casualties, to identify hazardous conditions or situations and to conduct statistical analysis. The
information is used to determine whether new or revised safety initiatives are necessary for the protection of life or property in the marine
environment.
CG-2692B (11/12)

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