US Water Patrol Incident Report
Incident Report No.__________
Last Name_______________________First_____________________M.I.______Age_____
Mailing Address_______________________
City________________State______Zip______
Home Phone.______-______-_________ Cell Phone.______-______-_________
Date of incident______________
Weather Light Level River Condition
Clear._________ Dawn.__________ High.__________
Time of incident.__________
Cloudy._______Daylight._______Low.____Rain.____Dusk._____Swift._______
Location Type of Incident
Water._____ Land._____ Dock.____ Building.______ Dam._______ Road.______ Boat Ramp._____ Boat._______
Jet Ski.______ Island._____ Power Plant._____ Accident.______ Sinking.______ Disabled._____ Grounding._____
medical._____ Security._____ Undertow._____ Other.______
Boat size.______ Type of boat .__________
Number of people on Board._____
INCIDENT INFORMATION
Boat number & Name. ________________________________________________
Port.___________________________________________
Source of information.
___________________________________________________________________________________________
Exact location of incident.
________________________________________________________________________________________________ Describe Nature of Incident. ____________________________________________________________________________________________
____________________________________________________________________________________________
IMMEDIATE ACTION TAKEN
Medical_____ Police Notified______ Fire Notified._____ Towed_____ Fueled______ Documented_____

Officer Name (print). ________________________________________
Date & Time.__________________________
Officer's Dept. and Address
________________________________________________________________________________________________ ________________________________________________________________________________________________
Officer Signiture.______________________________
uswp-101-04