River Barge Crew Illness Incident Self-Report Form
Date of Report
Crew Member Name
Crew Position/Role
Vessel/Barge Name
Date Illness Noticed
Time Illness Noticed
Describe Symptoms
Actions Taken (e.g. Self-isolation, Medical Attention Sought)
Are Other Crew Members Affected?
Yes
No
If Yes, Please List Other Names
Medical Assistance Contacted?
Yes
No
If Yes, Provide Details
Additional Comments