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Injury Report: Details of Injured Person

The injury report form is used to document any injuries that occur. It requests details about the injured person such as their name, rank, nationality, date of birth, and address. It also requires a description of the injury including its nature, location on the body, and any additional comments. The form documents whether first aid was administered and includes spaces to describe any medical treatment both initially and if the person was taken ashore. Attachments of medical reports are also to be included. The back of the page can be used for additional comments. The injured person and safety officer must sign the form. It is to be kept by the safety officer and a copy sent with any accident report.

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4K views2 pages

Injury Report: Details of Injured Person

The injury report form is used to document any injuries that occur. It requests details about the injured person such as their name, rank, nationality, date of birth, and address. It also requires a description of the injury including its nature, location on the body, and any additional comments. The form documents whether first aid was administered and includes spaces to describe any medical treatment both initially and if the person was taken ashore. Attachments of medical reports are also to be included. The back of the page can be used for additional comments. The injured person and safety officer must sign the form. It is to be kept by the safety officer and a copy sent with any accident report.

Uploaded by

opytnymoryak
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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INJURY REPORT

Company Forms and Check Lists

Date : 03.04.01
Rev.No : 1
Prep. : MGV
App. : CAP
Section: 02
Page : 1 of 2

Please complete one for each injured person and attach it in the Accident report. Other related documents such as
medical reports should also be included and attached in the accident report.

Details of Injured Person


Name
Rank
Nationality
Date of Birth
Address :

Sex: Male / Female

Description of Injury
Nature of Injury :

...............................................................................

Body Location :

...............................................................................

Additional Comments :

.........................................................................

...............................................................................................
...............................................................................................

Medical Treatment
First Aid treatment administered.

Yes/No

Particulars of medical treatment:

................................................................
..............................................................................................
...............................................................................................
...............................................................................................
..............................................................................................
Was Injured taken ashore for further medical attention ?
Yes/No
Particulars of medical treatment:

................................................................
...............................................................................................
...............................................................................................
...............................................................................................
...............................................................................................
(Attach Copy of Doctor's medical Report)
Please use the back of this page for any additional comments or statements relative to this injury.
Additionally if the injured wishes to indemnify the company in relation to this incident please have the
statement signed.

Safety Officer

Signature

C:\FORMS\02_0016.PDF

MT LADON

INJURY REPORT
Company Forms and Check Lists

Date : 03.04.01
Rev.No : 1
Prep. : MGV
App. : CAP
Section: 02
Page : 2 of 2

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Safety Officer

Injured Person

Signature

Signature

INSTRUCTIONS :
To be filled in every time there is an injury . To be kept in Safety Officer's file and a copy to be sent to the office
attached to the relevant incident report.

C:\FORMS\02_0016.PDF

MT LADON

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