PBO G 02 F07 Incident report


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Name of vessel _______________________________

Port of Registry ________________________

TYPE OF INCIDENTS:

Accident Hazardous Occurrence Other*

* e.g. technical defect

DETAILS OF INCIDENT:

Date of Incident ________________________ Time _______________

On board incident Place on ship _________________________

At sea Lat: _____________ Long: ______________

Incident in Port Port name ____________________________

WITNESSES DETAILS (names & ranks):

IN CASE OF PERSONAL INJURY:

Name: ____________________________________

Birth Date: ________________________________

Rank/Rating: ______________________________

Seaman Discharge Book No.: _______________

Nationality: _______________________________

Home address: ____________________________

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 ________________________________

DESCRIPTION OF INCIDENT:

Cause of incident, recommendations:

Any other documents attached:

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



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