Form Cg 2692B PDF Details

In the realm of maritime safety and oversight, the CG 2692B form plays a pivotal role, safeguarding the waters and individuals who navigate them. Mandated by the Department of Homeland Security and specifically utilized by the U.S. Coast Guard, this form is integral following a serious marine incident involving vessels in commercial service. Its primary purpose is to report on mandatory chemical drug and alcohol testing of the individuals directly involved in such incidents, aiming to establish a clear understanding of the circumstances that lead to these unfortunate events. The criteria for reporting include situations that result in deaths, injuries requiring more than first aid, significant damage to property, the total loss of vessels, and substantial environmental harm through oil spills or release of hazardous substances. The thorough completion and prompt submission of this form not only comply with federal regulations but also contribute significantly to enhancing maritime safety protocols. By analyzing incidents and the factors leading up to them, including the possible impairment from drugs or alcohol, the Coast Guard is equipped to identify hazardous conditions, inform future safety initiatives, and ultimately protect life and property in the marine environment.

QuestionAnswer
Form NameForm Cg 2692B
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names2018 serious marine incident form, uscg 719 b form, uscma forms, uscg 2692 form

Form Preview Example

 

 

 

 

DEPARTMENT OF HOMELAND SECURITY

 

 

OMB No: 1625-0001

 

 

 

 

 

 

 

U.S. Coast Guard

 

 

 

 

Exp. Date: 03/31/2019

 

REPORT OF MANDATORY CHEMICAL TESTING FOLLOWING A SERIOUS MARINE INCIDENT

 

 

 

INVOLVING VESSELS IN COMMERCIAL SERVICE

 

 

 

 

 

 

Note: This form shall be used to report data on persons directly involved in a serious marine incident involving a vessel in commercial service and the

 

mandatory chemical drug and alcohol testing.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section I - Reporting Vessel Information - Casualty Date/Time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Vessel Name

 

 

 

 

2. Vessel Official Number or IMO Number

 

 

3. Date/Time (local) of Occurrence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section II - Reason for Submitting this Report (Check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. The above vessel is in commercial service and was involved in a Serious Marine Incident that resulted in (46 CFR 4.03-2):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

One or more deaths

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

An injury to a crewmember, passenger, or other person that 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

 

 

 

 

 

 

 

 

Damage to property in excess of $200,000

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Actual or constructive total loss of any vessel subject to inspection under 46 USC 3301

 

 

 

 

 

 

 

 

 

 

 

Actual or constructive total loss of any self-propelled vessel, not subject to inspection under 46 USC 3301, of 100 gross tons or more

 

 

 

 

 

 

A discharge of oil of 10,000 gallons or more into the navigable waters of the United States, as defined in 33 USC 1321

 

 

 

 

 

 

 

 

A discharge of a reportable quantity of a hazardous substance into the navigable waters of the United States

 

 

 

 

 

 

 

 

 

A release of a reportable quantity of a hazardous substance into the environment United States

 

 

 

 

 

 

 

 

 

 

 

 

 

Section III - Personnel and Testing Information

 

 

 

 

 

 

 

5. Individuals Directly Involved in Serious Marine Incident

6. Drug and Alcohol Testing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5b. USCG

 

6a. Drug Test Urine Sample

6b. Alcohol Test Specimen

6c. Type of Alcohol Test

 

6d. Alcohol

5a. Name (Last, First, Middle)

 

Credentialed?

Provided Within 32 Hours?

Provided within 2 Hours?

Specimen Provided

 

Test Results

 

 

 

Yes

No

 

Yes

No

Refused

Yes

No

Refused

Saliva

Blood

Breath

 

 

 

 

 

 

Yes

No

 

Yes

No

Refused

Yes

No

Refused

Saliva

Blood

Breath

 

 

 

 

 

 

Yes

No

 

Yes

No

Refused

Yes

No

Refused

Saliva

Blood

Breath

 

 

 

 

 

 

Yes

No

 

Yes

No

Refused

Yes

No

Refused

Saliva

Blood

Breath

 

 

 

 

 

 

Yes

No

 

Yes

No

Refused

Yes

No

Refused

Saliva

Blood

Breath

 

 

 

 

 

 

Yes

No

 

Yes

No

Refused

Yes

No

Refused

Saliva

Blood

Breath

 

 

 

 

 

 

Yes

No

 

Yes

No

Refused

Yes

No

Refused

Saliva

Blood

Breath

 

 

 

 

 

 

Yes

No

 

Yes

No

Refused

Yes

No

Refused

Saliva

Blood

Breath

 

 

 

 

 

 

Yes

No

 

Yes

No

Refused

Yes

No

Refused

Saliva

Blood

Breath

 

 

 

 

 

 

Yes

No

 

Yes

No

Refused

Yes

No

Refused

Saliva

Blood

Breath

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. Explanation of why test samples were not collected within required timeframes or not at all and/or why testing was not conducted (Required for each “No” checked in columns 6a or 6b)

8. SAMHSA Accredited Laboratory Conducting Chemical Drug Tests

9. Laboratory or Individual Conducting Alcohol Tests

Name:

Name:

Address:

Address:

Telephone:

Telephone:

Email:

Email:

 

 

Section IV - Person Making this Report

10.

Name (PRINT) (Last, First, Middle)

11.

Signature

12. Date

 

 

 

 

 

13.

Title

14.

Address

 

 

 

 

 

 

15.

Telephone No.

16.

Email

 

 

 

 

 

 

CG-2692B (04/18)

Page 1 of 2

 

 

RESET

 

INSTRUCTIONS FOR COMPLETION OF FORM CG-2692B

Report of Chemical Testing Following a Serious Marine Incident Involving a Commercial Vessel

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 or submitted alone, satisfies the requirement found in the Code of Federal Regulations for written reports of chemical drug and alcohol testing of individuals engaged or employed on board a commercial vessel who are identified as being directly involved in serious marine incidents consisting of one or more of the occurrences lists in block 4. Alcohol tests are to be conducted not later than 2 hours (unless there are safety concerns directly related to the casualty that need to be addressed by the individual(s)) and drug test specimens collected not later than 32 hours after a serious marine incident.

INDIVIDUAL DIRECTLY INVOLVED IN A SERIOUS MARINE INCIDENT

2.The term "individual Directly Involved in a Serious Marine Incident" means 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

3.In accordance with 46 CFR Subpart 4.06 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 10 individuals are directly involved in the Serious Marine Incident additional CG-2692Bs 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. http://www.uscg.mil/top/units/

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 5a of this form to the Coast Guard Officer in Charge, Marine Inspection where the CG-2692B was submitted in accordance with 46 CFR §4.06-60(d).

7.Block 6d - Alcohol Test Result: When the alcohol test results are available, the alcohol concentration shall be expressed numerically in percent by weight (i.e. 0.04, 0.10, etc.); otherwise indicate positive for alcohol being present or negative for no alcohol present.

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-2692B (04/18)

Page 2 of 2

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