ISLAND SHIP MANAGEMENT LTD.

ISM73
On-Board Complaint-Handling Form
船上投诉处理表
This form is to be filled by the complainant or complainant’s representative. If the complaint involves allegation against any other
seafarer, which may be regarded as personal, private or intimate, such seafarer may not be referred to in an identifiable way in
writing this form. 此表由投诉人或投诉人代表人填写。如果此投诉涉及对任何其他海员的个人隐私或亲密的控诉，被涉及的海
员不应被明确地填写在此表上

Ship’s Particulars 船舶信息

Vessel 船舶: Date 日期: Place 地点:
                 

Complainant’s Particulars 投诉详情

Designation 职位: Name / Passport No 名字/护照号码.: Date of Birth 生日:
                 

Complainant’s Representative’s Particulars (if any) 投诉人代表详情（如有）

Designation 职位: Name / Passport No.名字/护照号码: Date of Birth 生日:
                 
Declaration 声明:
I confirm that I have agreed and accepted to accompany and/or to represent the complainant, and to attend any meetings into
the subject matter of the complaint
我确认，我同意和愿意陪同/或代表投诉人出席投诉会议 Signature 签名: __________________
________

Briefly describe the complaint (including date, time and place of event and persons involved or witnesses):
简略描述投诉内容（包含日期，时间，地点）
     
     
     
     
     
     
     
     
     
     
     
     
     
Declaration 声明:
I confirm that I have not been penalized or victimized in any way for filing this complaint, and that I have been informed that
lodging this complaint is without prejudice to my right to seek redress through whatever legal means I consider appropriate.
我确认，我没有受到处罚或迫害的任何方式来提交这投诉，而且我已被告知，这投诉没有损害我的权利，在我认为适当的
时候可以寻求任何法律手段。
I declare that all the information submitted by me in this On-Board Complaint Form is correct and does not contain any false
information. I declare that I have not omitted any relevant information and that my complaint is not unjustified.
我声明，我在这船上投诉表格上提交的所有信息是正确的，不存在任何虚假记载。我声明，我没有遗漏任何相关的信息和
我的投诉是正当的。
I accept that this matter may be referred to the Master for resolution and the Master will inform me of the outcome.
我承认这件事情会干涉船长的决议，船长会将结果通知我。
Signature of the Complainant 投诉人签名: ______________________

Acknowledged by Depart. Head, Seafarer’s Superior Officer or Master

分管主管，部门主管，上司 或 船长受理此投诉
Head of Section Department 分管主管
Resolution or reply shall be not later than one working day upon receipt of the complaint.
Form : On-Board Complaint Form Distribution Issue : 0
File : ISM73 DPA/PM/Retain onboard Revision : 0
Original Issue : June 2013 Frequency :if require Page 1 of 2
 ISLAND SHIP MANAGEMENT LTD.
解决或答复最迟不应晚于接到投诉后 1 个工作日
NAME 姓名:       Rank 职务：      RECEIVED DATE 收到日期:      
REPLY 答复意见：     
     
     
Head of Department 部门主管
Resolution or reply shall be not later than Three working days upon receipt of the complaint.
解决或答复最迟不应晚于接到投诉后 3 个工作日
NAME 姓名:       Rank 职务：      RECEIVED DATE 收到日期:      
REPLY 答复意见：     
     
     
Master 船长
Resolution or reply shall be not later than Three working days upon receipt of the complaint.
解决或答复最迟不应晚于接到投诉后 3 个工作日
NAME 姓名:       Rank 职务：      RECEIVED DATE 收到日期:      
REPLY 答复意见：     
     
     
Meeting to Resolve Complaint 投诉处理会议
The matter has been resolved 投诉已解决: Yes 是 / 否 No / Other 其它
If No, please state reason 如否，请阐述原因:      
     
     
     
If No ~ The matter has been referred to the Company for resolution on ~ 如否，这投诉已提交公司解决
Date/Month/Year 提交的时间 日/月/年：     
If other, please state organization 如果提交给其它机构，机构名称：
     
Marine Personnel Department Manager 船员部经理
Resolution or reply shall be not later than Seven days upon receipt of the complaint.
解决或答复最迟不应晚于接到投诉后 7 个工作日
NAME 姓名:       Rank 职务：      RECEIVED DATE 收到日期:      
REPLY 答复意见：     
     
     
Satisfied with the Complain-handling result 对投诉处理结果满意
Acknowledged by Complainant 投诉人确认 Signature by Master of Vessel 船长签名
Name and Signature 名字和签名:       Name and Signature 名字和签名:      
Date 日期:       Date 日期:      
Acknowledged by Complainant’s Representative (if any)
投诉代理人（如有）
Name and Signature 名字和签名:      
Date 日期:      

Form : On-Board Complaint Form Distribution Issue : 0

File : ISM73 DPA/PM/Retain onboard Revision : 0
Original Issue : June 2013 Frequency :if require Page 2 of 2