DRAFT_CG-2692D Involved Persons and Witness Addendum

OMB No. 625-0001
Exp. Date: 01/31/2016

DEPARTMENT OF HOMELAND SECURITY
U.S.COASTGUARD

Involved Persons and Witnesses Addendum
Note: This form shall be used to report data on persons involved or witnessing an OCS-related casualty 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 – Involved Persons and Witnesses Details:
3a. Name (Last, First, Middle)
3d. Address

3b. Relationship to Vessel or Facility:

3c. Status:

__ Crew – Position: ________________________________

__ Involved Person

__ Passenger

__ Witness

__ Other – Describe: _______________________________
3e. Telephone
4a. Name (Last, First, Middle)

4b. Relationship to Vessel or Facility:

4c. Status:

__ Crew – Position: ________________________________

__ Involved Person

__ Passenger

__ Witness

4d. Address
__ Other – Describe: _______________________________
4e. Telephone
5a. Name (Last, First, Middle)

5b. Relationship to Vessel or Facility:

5c. Status:

__ Crew – Position: ________________________________

__ Involved Person

__ Passenger

__ Witness

5d. Address
__ Other – Describe: _______________________________
5e. Telephone
6a. Name (Last, First, Middle)
6d. Address

6b. Relationship to Vessel or Facility:

6c. Status:

__ Crew – Position: ________________________________

__ Involved Person

__ Passenger

__ Witness

__ Other – Describe: _______________________________
6e. Telephone
7a. Name (Last, First, Middle)

7b. Relationship to Vessel or Facility:

7c. Status:

__ Crew – Position: ________________________________

__ Involved Person

__ Passenger

__ Witness

7d. Address
__ Other – Describe: _______________________________
7e. Telephone
8a. Name (Last, First, Middle)
8d. Address

8b. Relationship to Vessel or Facility:

8c. Status:

__ Crew – Position: ________________________________

__ Involved Person

__ Passenger

__ Witness

__ Other – Describe: _______________________________
8e. Telephone
9a. Name (Last, First, Middle)

9b. Relationship to Vessel or Facility:

9c. Status:

__ Crew – Position: ________________________________

__ Involved Person

__ Passenger

__ Witness

9d. Address
__ Other – Describe: _______________________________
9e. Telephone
10a. Name (Last, First, Middle)
10d. Address

10b. Relationship to Vessel or Facility:

10c. Status:

__ Crew – Position: ________________________________

__ Involved Person

__ Passenger

__ Witness

__ Other – Describe: _______________________________
10e. Telephone

CG-2692D (Rev. XX-15)

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INSTRUCTIONS FOR COMPLETION OF FORM CG-2692C
INVOLVED PERSONS AND WITNESSES ADDENDUM
Note: This form shall be used to report data on persons involved or witnessing an OCS-related casualty described on form CG-2692 and may be used to report data on persons involved or witnessing a
marine casualty or commercial diving casualty 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 OCS-related casualties
on OCS Facilities or vessels engaged in OCS activities. Specifically, it provides information on one or more persons who were involved in or witnessed the casualty. This form may only be used in
addition to form CG-2692, never alone.
COMPLETION OF THIS FORM
2. 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 8 individuals were involved in or witnessed the casualty, additional CG-2692Ds 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-2692D (Rev. XX-15)

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