Title Page
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Conducted on
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Prepared by
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Location
1. Originator
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Name:
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Position:
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Report Type:
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Report Origin:
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Description of Non-conformance or Opportunity for Improvement request:
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Shore-based Manager:
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Response Date:
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Master's Signature:
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Date:
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WHEN COMPLETE, SEND TO SHORE-BASED MANAGER
2. Shore-based Manager - Proposed Action
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For Corrective/Preventative Actions, please indicate:
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Root Cause of Problem
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Proposed Corrective/Preventative Action:
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Proposed Completion Date
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Disposition
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Date:
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Copy to Designated Person - Designated Person Signature
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Date:
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Description of Action(s) taken:
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Completion Date:
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Shore-based Manager's Signature
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SEND BACK TO MASTER FOR QUALITY ASSURANCE FOLLOW UP
3. Quality Assurance - Master Follow up
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Problems successfully addressed?
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Signature:
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Date:
