Name of vessel _______________________________ |
Port of Registry ________________________ |
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TYPE OF INCIDENTS: Accident Hazardous Occurrence Other* * e.g. technical defect |
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DETAILS OF INCIDENT: Date of Incident ________________________ Time _______________ |
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On board incident Place on ship _________________________ |
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At sea Lat: _____________ Long: ______________ |
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Incident in Port Port name ____________________________ |
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WITNESSES DETAILS (names & ranks):
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IN CASE OF PERSONAL INJURY: |
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Name: ____________________________________ |
Birth Date: ________________________________ |
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Rank/Rating: ______________________________ |
Seaman Discharge Book No.: _______________ |
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Nationality: _______________________________ |
Home address: ____________________________ |
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Has injury incapacitated injured seaman from work? Yes No If yes, period of incapacity ___________ days. Was injured seaman discharged through injury? Yes No If yes, state name of Port and Date ________________________________ |
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DESCRIPTION OF INCIDENT:
Cause of incident, recommendations:
Any other documents attached: |
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SIGNATURES:
____________________________ Ch. Officer/Ch. Engineer's Signature / Date |
____________________________ Master's Signature / Date |
Note: This form is to be completed in triplicate; two copies to be sent to the Office each for DPA and relevant Div. and the remaining copy to be kept on board. To retain for 2 years.
Issue date: 03.11.2003/Rev. 00 PBO-G*02-F07 Page: 1/1
INCIDENT REPORT
QSMS PBO*02-F07 Rev. No.00