No: R 03

POSEIDON SA Page:
Date:
1 of 1
01/12/15
Rev.: 0
PERSONAL INJURY REPORT
Vessel: Date: Ref:

PERSONAL DETAILS OF SEAFARER/ SHORE WORKER (DELETE AS NECESSARY)

Name: Rank / Occupation:

Date of Birth: Nationality:

RESULTS OF ACCIDENT INJURY DEATH MISSING DISEASES

Incident Data Location of Incident Weather at time of incident: Lighting at time of incident:
Date: Onboard Good Good
Time:
Ashore Moderate Moderate
Reported by: Port: Bad Bad

Reported to: Lat:

Icy Nature

Lon: Other Other

INJURIES SUSTAINED
Nature: Body location:
Medical treatment given on board: By whom:
Description of Accident:

(Please Continue on Separate Sheets As Necessary)

Actions Taken:

Masters Name: Signature: Investigation carried out Signature:

by:

Agree with actions taken: YES Date Reviewed by SM: SM Signature:

NO*
*If NO, please, issue further NEW instructions

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