DRAFT_CG-2692C Personnel Casualty Addendum

OMB No.1625-0001
Exp. Date: 01/31/2016

DEPARTMENT OF HOMELAND SECURITY
U.S.COASTGUARD

Personnel Casualty Addendum
Note: This form shall be used to report data on persons who were injured, killed, or are missing as a result of the marine casualty/accident described on form CG-2692.
This form may only be used in addition to form CG-2692, never alone.

Section I - Reporting Vessel/Facility Information – Incident Date/Time:
1. Vessel or Facility Name

2. Date/Time (local) of Occurrence

Section II – Injured, Dead, and Missing Person Details:
3a. Name (Last, First, Middle)
3d. Address

3b. Relationship to Vessel or Facility:

__ Injured

__ Passenger

__ Dead

__ Other – Describe: _______________________________
3e. Telephone

3c. Status:

__ Crew – Position: ________________________________

3f. For Crew – On Duty at Time?
__ Yes

3g. Date of Birth:

__ Missing
3h. Date of Death:

__ No

3i. Activity of Person at Time of Accident:
3j. Location on Vessel or Facility where Accident Occurred:
3k. Extent of Injuries to Person (Parts of Body and Type of Injuries):
4a. Name (Last, First, Middle)
4d. Address

4e. Telephone

4b. Relationship to Vessel or Facility:

4c. Status:

__ Crew – Position: ________________________________

__ Injured

__ Passenger

__ Dead

__ Other – Describe: _______________________________

__ Missing

4f. For Crew – On Duty at Time?
__ Yes

4g. Date of Birth:

4h. Date of Death:

__ No

4i. Activity of Person at Time of Accident:
4j. Location on Vessel or Facility where Accident Occurred:
4k. Extent of Injuries to Person (Parts of Body and Type of Injuries):
5a. Name (Last, First, Middle)
5d. Address

5e. Telephone

5b. Relationship to Vessel or Facility:

5c. Status:

__ Crew – Position: ________________________________

__ Injured

__ Passenger

__ Dead

__ Other – Describe: _______________________________

__ Missing

5f. For Crew – On Duty at Time?
__ Yes

5g. Date of Birth:

5h. Date of Death:

__ No

5i. Activity of Person at Time of Accident:
5j. Location on Vessel or Facility where Accident Occurred:
5k. Extent of Injuries to Person (Parts of Body and Type of Injuries):
6a. Name (Last, First, Middle)
6d. Address

6b. Relationship to Vessel or Facility:

__ Injured

__ Passenger

__ Dead

__ Other – Describe: _______________________________
6e. Telephone

6c. Status:

__ Crew – Position: ________________________________

6f. For Crew – On Duty at Time?
__ Yes

6g. Date of Birth:

__ Missing
6h. Date of Death:

__ No

6i. Activity of Person at Time of Accident:
6j. Location on Vessel or Facility where Accident Occurred:
6k. Extent of Injuries to Person (Parts of Body and Type of Injuries):
7a. Name (Last, First, Middle)
7d. Address

7e. Telephone

7b. Relationship to Vessel or Facility:

7c. Status:

__ Crew – Position: ________________________________

__ Injured

__ Passenger

__ Dead

__ Other – Describe: _______________________________

__ Missing

7f. For Crew – On Duty at Time?
__ Yes

7g. Date of Birth:

7h. Date of Death:

__ No

7i. Activity of Person at Time of Accident:
7j. Location on Vessel or Facility where Accident Occurred:
7k. Extent of Injuries to Person (Parts of Body and Type of Injuries):

CG-2692C (Rev. XX-15)

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INSTRUCTIONS FOR COMPLETION OF FORM CG-2692C
PERSONNEL CASUALTY ADDENDUM
Note: This form shall be used to report data on persons who were injured, killed, or are missing as a result of the marine casualty/accident described on form CG-2692.
This form may only be used in addition to form CG-2692, never alone.
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 (CG-INV), U.S. Coast
Guard Stop 7501, 2703 Martin Luther King Jr Ave SE, Washington, DC 20593-7501 or Office of Management and Budget, Paperwork Reduction Project (1625-0001), Washington, DC 20503.
WHEN TO USE THIS FORM
1. This form, when submitted in conjunction with a CG-2692, satisfies the requirement for written reports of casualties and accidents found in the Code of Federal Regulations for vessels. Specifically, it
provides information on one or more persons who were injured, dead or missing a result of their involvement in a reportable marine casualty, commercial diving casualty, or an OCS-related casualty. This
form may only be used in addition to form CG-2692, never alone.
DEFINITIONS
2. Loss of life – a life is considered lost when the person is known to be deceased (e.g. the body has been recovered), the person has been categorized as “presumed lost/dead” by agencies leading
search and rescue efforts, or the circumstances of the occurrence make recovery of the person alive unlikely
3. Injury - defined as damage or harm caused to the structure or function of the body as a result of an outside physical agent. Damage or harm caused exclusively by animal/insect bites/scratches is
excluded. Pursuant to the Occupational Safety and Health Administration’s (OSHA) definition of “injury or illness” in 29 CFR 1904.46, the Coast Guard considers injuries and illnesses as separate types of
occurrences. As such, damage or harm caused by illness, including but not limited to: communicable illness (i.e. colds, flu, etc.), food poisoning, heart attack, stroke, or other pre-existing medical
condition is not considered an injury and does not fall under this criterion.
COMPLETION OF THIS FORM
3. In accordance with 46 CFR §4.05-10, 46 CFR §197.486,and 33 CFR §146.35 this form shall be filled out as completely and accurately as possible. Please type or print clearly. Fill in all blanks that
apply to the kind of accident that has occurred. If a block is not applicable, the abbreviation “NA” should be entered in that space. If the answer is unknown and cannot be obtained before the report has
to be submitted (i.e. within 5 days of the accident), the abbreviation “UNK” should be entered in that block. If “NONE” is the correct response, enter it in the block.
4. If more than 5 individuals were injured, dead, or missing as a result of the marine casualty additional CG-2692Cs should be completed.
5. Once completed, deliver, email, or fax this form with a corresponding CG-2692 within 5 days of the casualty to the Coast Guard Sector, Marine Safety Unit, or Activity nearest the location of the
casualty or, if at sea, nearest the arrival port.
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-2692C (Rev. XX-15)

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