U.S. DEPARTMENT OF HOMELAND SECURITY U.S. COAST GUARD CG-4917 (Rev. 9-05)
Mail to: Commandant (G-OPB-3), USCG, Washington, DC 20593-0001
OMB NO. 1625-0010
An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it CAMPAIGN NUMBER displays a valid OMB control number. The Coast Guard estimates that the average burden for this report form is one hour. You may submit any comments concerning the accuracy of this burden estimate or any suggestions for reducing the burden to: Commandant (G-OPB-3), U.S. Coast Guard, Washington, DC 20593-0001 or Office of Management and Budget, Paperwork Reduction Project (1625-0010), Washington, DC 20503.
1. NAME AND ADDRESS OF COMPANY CONDUCTING DEFECT NOTIFICATION CAMPAIGN (include ZIPCODE)
2. NAME AND PHONE NUMBER OF PERSON TO CONTACT 3. IF DEFECTIVE COMPONENT, MANUFACTURER NAME AND ADDRESS:
4a. IDENTIFICATION OF BOATS POTENTIALLY INVOLVED (use other means or additional space on Page 2 if necessary): MODEL MODEL MODEL MODEL HIN HIN HIN HIN to to to to
4b. IF PRODUCTS INVOLVED ARE NOT BOATS (use other means or additional space on Page 2 if necessary): MODEL MODEL MODEL SERIAL NOS. SERIAL NOS. SERIAL NOS. to to to YEAR YEAR YEAR
5. DESCRIPTION OF DEFECT OR NONCOMPLIANCE:
6. DEGREE OF DANGER TO THE PUBLIC WITH CONTINUED USE OF THE PRODUCT WITHOUT REPAIR OR CORRECTION:
7. MANNER IN WHICH PRODUCTS RECALLED WILL BE CORRECTED (use additional space on Page 2 if necessary):
a. Who will perform corrections?
b. Where will corrections be performed?
PREVIOUS EDITIONS ARE OBSOLETE
c. When will corrections be performed?
d. How will corrections be performed?
8. ACTIONS TAKEN TO DATE TO CORRECT THIS DEFECT OR NONCOMPLIANCE:
9. LOCATION OF UNITS: a. Number of units sold to consumers: b. Number of units at the factory: c. Number of units shipped to dealers: d. Locations of other units:
10. CURRENT STATUS OF CAMPAIGN: a. Number of units which might contain the problem: b. Number of first purchasers notified about the problem: c. Number or dealers or distributors notified about the problem: d. Number of units corrected or repaired: e. Number of units inspected which did not have problem: f. Number of owners who refused the offer to repair or correct (an owner who refuses must do so in writing)
11. IF ANY OF THE INFORMATION REQUESTED IN 9. AND 10. ABOVE IS NOT AVAILABLE WHEN SUBMITTING THIS REPORT, WHEN WILL THE INFORMATION BE AVAILABLE?
THIS FORM IS AUTHORIZED BY 46 U.S.C. CHAPTER 43 AND 33 CFR 179 FOR THE COLLECTION OF INFORMATION CONCERNING THE PRODUCTS INVOLVED IN THIS DEFECT NOTIFICATION AND RECALL CAMPAIGN. THE INFORMATION PROVIDED ON THIS FORM WILL BECOME A PART OF THE OFFICIAL U.S.COAST GUARD FILE COVERING THIS CAMPAIGN AND WILL BE USED IN EVALUATING THE DILIGENCE WITH WHICH YOUR COMPANY CONDUCTS THIS CAMPAIGN. FAILURE TO SUBMIT THIS REPORT FORM WITHIN SPECIFIED TIME CONSTRAINTS CAN RESULT IN A CIVIL PENALTY OF $1000. SIGNATURE AND TITLE OF PREPARER: SPACE FOR ADDITIONAL INFORMATION: List the model name, length, model year and type of propulsion for boats for which affected Hull Identification Number (HIN) sequences in item 4a. are not available DATE:
THE COAST GUARD MUST RECEIVE THIS REPORT ON OR BEFORE: