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Chicago
Gananoque
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City
Destinations
Alexandria
Baltimore
Berkeley
Boston
Chicago
Gananoque
London
Long Beach
Marina del Rey
Newport Beach
New Jersey
New York
Norfolk
Philadelphia
Poole
Sacramento
San Diego
San Francisco
Toronto
Washington DC
York
800-459-8105
Book Now
Plan an Event
Gift Cards
Dining Cruises
All Dining Cruises
Dinner
Brunch
Cocktail
Holiday
Private Events
Private Events
Social Events
Corporate Events
Weddings
Nightlife
Schools
Tours + Sightseeing
Tours + Sightseeing
Harbor Cruises
River Cruises
New York Sightseeing Tours
Whale Watching Tours
Things To Do
Plan an Event
I. BASIC INFORMATION: Check all that apply
Location
Landing
Office
Shore-side
Vessel
Warehouse
Other
Identify name / location
Date
Date Format: MM slash DD slash YYYY
Time
:
HH
MM
AM
PM
Service / Route, if applicable:
Closest Shore-side Landing:
Person(s) Involved:
Employee
Passenger
Other
Area where incident occurred:
Name(s) of Those Involved: (First / Last)
INCIDENT SUMMARY
II. TYPE OF INCIDENT: Check all that apply
Type of Incident
Injury / Illness
Operations
Near-Miss
Injury / Illness
Amputation / Loss of Limb
Blood Loss
Breathing Difficulties / Shortness
Bump / Bruise
Burn
Chest Pain
Cut
Dislocation
Electric Shock
Fainted / Passed-out
Illness, Heat-related
Illness, Mental / Emotional
Illness, Physical Health
Ingestion (Chemical, Hazardous, etc...)
Loss of Consciousness
Rash
Seizure
Sprain / Strain
Substance Abuse (Alcohol, Drugs, etc..)
Vomiting / Sea Sickness
Beyond Basic First Aid
First Aid Offered, but DECLINED
First Aid Offered, but DECLINED
Operations
Collision / Allision
Damage to Equipment
Damage to Landing
Damage to Other
Damage to Vessel
Electricity
Employee(s) Disturbance
Equipment Failure (Loss of Streering, Propulsion)
Fire
Gangway
Grounding
Hard Landing
Line Parting / Snap-back / Damage
Man Overboard / Rail-jumper
Mechanical Breakdown
Passenger / Public Disturbance
Physical Altercation / Conflict
Security, Break of
Slip, Trip, Fall
Smoke / Smolder
Spill, Release to Environment
Spill, Contained
Struck by Object
Suspicious Activity
Theft
Other:
If Other:
Near-Miss
Damage
Equipment-related
Fall into Water
Injury
Lock-out / Tag-out
Mooring Line Condition
Operator Error
Open Hatch, Unprotected
Mechanical
Navigation
Safety
Shared Waterways (Vessel Traffic)
Other:
If Other:
Party(s) Involved
Passenger / Rider / Guest
Contractor / Third party
Crew, Vessel
Crew, Shore-side
Other:
If Other:
III. INCIDENT DETAILS: Check all that apply
Location:
(Vessel, Shore-side, etc..)
Service / Route:
Physical Area:
Number of Passenger Onboard:
Type N/A if not applicable
Vessel
Underway
At Pier / Dock
Departing
Landing
N/A
Body Part(s) Affected
Check all that apply (If, Applicable)
Head Area
Upper Body
Lower Body
Other
Head Area
Back of Head
Nose
Top of Head
Chin
Face
Eye(s)
Mouth / Lip
Teeth
Upper Body
Shoulder
Back
Chest
Neck
Abdomen
Arm
Hand
Wrist
Elbow
Finger
Lower Body
Hip
Foot
Groin
Toe
Upper Leg
Lower Leg
Knee
Ankle
Describe, if Other
Environment:
(Weather, Visibility, Physical Elements, Lighting, Vessel Traffic)
Weather
Wind Speed: (enter below)
Wind Direction: (enter below)
High Tide
Low Tide
Flood Current
Ebb Current
Slack Water
Rain
Temperature: (enter below)
Snow / Sleet
N/A
Wind Speed
Wind Direction
Temperature
Visibility
Poor
Moderate
Good
Excellent
Physical Elements
Water on Deck
Wet Ground
Ice
Debri, floating
Debri, on ground/deck
N/A
Lighting
Poor
Moderate
Good
Vessel Traffic
Light
Moderate
Heavy
N/A
IV. AFFECTED PARTY DETAILS:
Party Options
Party Refused to Provide Information
Party Refused Medical Attention
Party Requested Ambulance
Party Requested Copy of Incident Report
Name:
Contact Number:
Contact Email:
Home Address
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of Birth:
Date Format: MM slash DD slash YYYY
Gender
Male
Female
Undisclosed
Type of Footwear Worn:
Open-toe/Sandal
Sneaker
Shoe
Boot
Other:
N/A
If Other
Hospital location, if appl:
Requested Medical Treatment?
Yes
No
N/A
First Aid Administered?
Yes
No
N/A
By Whom?
(Print Name)
Witness to Incident?
Witness Name:
Withness Contact Number:
Witness Contact Email
V. ADDITIONAL DETAILS:
Captain
(Full Name)
Knowledge of Incident:
Yes
No
Post Incident Drug & Alcohol Testing Completed (Check all that apply)
Alcohol
Drug
First Officer:
(Full Name)
Knowledge of Incident:
Yes
No
Post Incident Drug & Alcohol Testing Completed (Check all that apply)
Alcohol
Drug
Deckhand:
(Full Name)
Knowledge of Incident:
Yes
No
Post Incident Drug & Alcohol Testing Completed (Check all that apply)
Alcohol
Drug
Deckhand:
(Full Name)
Knowledge of Incident:
Yes
No
Post Incident Drug & Alcohol Testing Completed (Check all that apply)
Alcohol
Drug
Other:
(Full Name)
Knowledge of Incident:
Yes
No
Post Incident Drug & Alcohol Testing Completed (Check all that apply)
Alcohol
Drug
Other:
(Full Name)
Knowledge of Incident:
Yes
No
Post Incident Drug & Alcohol Testing Completed (Check all that apply)
Alcohol
Drug
Other:
(Full Name)
Knowledge of Incident:
Yes
No
Post Incident Drug & Alcohol Testing Completed (Check all that apply)
Alcohol
Drug
Notification Made:
Supervisor Notified:
Yes
No
N/A
Dispatch Notified:
Yes
No
N/A
US Coast Guard Notified:
Yes
No
N/A
If yes, is CG-2692 required?
Yes
No
Law Enforcement Notified
Yes
No
N/A
Other(s) Notified
I have completed this form to the best of my ability regarding the incident at hand. I have made honest and accurate accounts to the best of my knowledge and I have not provided any false or dishonest statements or information.
Report Filled Out by:
Position:
Signature:
Date:
Date Format: MM slash DD slash YYYY