Form Cg 2692B – Fill Out and Use This PDF

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
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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)

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