Title Page

  • Conducted on

  • Prepared by

  • Location

1. Originator

  • Name:

  • Position:

  • Report Type:

  • Report Origin:

  • Description of Non-conformance or Opportunity for Improvement request:

  • Shore-based Manager:

  • Response Date:

  • Master's Signature:

  • Date:

  • WHEN COMPLETE, SEND TO SHORE-BASED MANAGER

2. Shore-based Manager - Proposed Action

  • For Corrective/Preventative Actions, please indicate:

  • Root Cause of Problem

  • Proposed Corrective/Preventative Action:

  • Proposed Completion Date

  • Disposition

  • Date:

  • Copy to Designated Person - Designated Person Signature

  • Date:

  • Description of Action(s) taken:

  • Completion Date:

  • Shore-based Manager's Signature

  • SEND BACK TO MASTER FOR QUALITY ASSURANCE FOLLOW UP

3. Quality Assurance - Master Follow up

  • Problems successfully addressed?

  • Signature:

  • Date:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.