Name of Person Reporting the Discrepancy

Date of Report

Department/Vessel

State the nature of the discrepancy

What is the proposed corrective action(s)

Immediate Action(s)

Name(s) of Person(s) to Implement Immediate Action(s)

Date for Completion

Futher Action(s)

Name(s) of Person(s) to Complete Further Action(s)

Follow-Up Details (Explain how the corrective action was verified)

Corrective Action(s) Closed Out

Person(s) Verifying Corrective Action

Priority of Completion

Please Choose Priority Highest Safety Priority High Priority Medium Low