Free CG2692B.PDF - Federal

U.S. DEPARTMENT OF HOMELAND SECURITY U.S. COAST GUARD CG-2692B (04-06)
1. Name of vessel

REPORT OF REQUIRED CHEMICAL DRUG AND ALCOHOL TESTING FOLLOWING A SERIOUS MARINE INCIDENT
(Sea Instructions on reverse)

APPROVED OMB NO. 1625-0001

Expiration Date: 10/31/2011

USCG MISLE ACTIVITY NUMBER

SECTION I--VESSEL INFORMATION
2. Official Number 6. Length 10. Master or Person in Charge Name: Address: Telephone Number: 3. Call Sign 7. Gross Tons 4. Nationality 8. Year Built 5. Vessel Type (Freight, Towing, Fishing, MODU, etc.) 9. Operating Company Name: Address: 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) b. Injury requiring medical treatment (Append to Form CG-2692) c. Property damage in excess of $100,000 (Append to Form CG-2692) d. Loss of inspected vessel (Append to Form CG-2692)
12. Date of Incident 13. Time (local) of Incident

e. Loss of uninspected, self-propelled vessel of over 100 gross tons (Append to Form CG-2692) f. Discharge of oil of 10,000 gallons or more into U.S. waters g. Discharge of a reportable quantity of hazardous substance into U.S. waters h. Release of a reportable quantity of hazardous substance into U.S. environment

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

SECTION III--PERSONNEL / TESTING INFORMATION
15. Personnel Directly Involved In Serious Marine Incident 15a. Name (Last, First, Middle Initial) 15b. Licensing/Certification (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 Alcohol Test Specimen provided Specimen provided Specimen Source within 32 hours? within 2 hours? YES NO YES NO
Breath Saliva Blood

Alcohol Test Results

__________________________ __________________________ __________________________ __________________________ __________________________
17. SAMHSA Accredited Laboratory Conducting Chemical Drug Tests Name: Address:

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

Telephone Number: 19. Person Making This Report (Please Print) Name: Address:

Telephone Number: 20. Signature

21. Date

Telephone Number:

Title:

22. Remarks (See Instructions on Reverse)

SN 7530-01-GF3-2380

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Page 2 of CG-2692B (Rev. 04-06)

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 nd estimate or any suggestions for reducing the burden to: Commandant (G-PCA-1), U.S. Cost Guard, 2100 2 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. 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.

6. 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)). 7. 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 16c--"ALCOHOL TEST BREATH SPECIMEN PROVIDED?" When breath test results are available 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. 22. REMARKS (Continued)

*U.S. GPO: 1991-282-640/26588

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