Cargo Ship Crew Exposure History Report

Vessel Information

Vessel Name IMO Number Voyage Number Date of Report

Exposure Details

Date & Time of Exposure Location (On Board / Port) Description of Exposure Incident Type of Substance/Agent Exposed To

Crew Member(s) Exposed

Name	Rank/Position	Crew ID	Nationality

Immediate Action Taken

Describe the Measures Taken

Medical Evaluation

Name of Medical Personnel Actions/Recommendations

Reporting Officer

Name Rank Signature Date

Remarks / Additional Information