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:

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