M/V ___________________________ Voyage No. _________________________ Date ____________________
S/N	Name	Rank	Date Joined	Remarks
1
2
3
4
Main Causes:
Suggestion:

Technical Superintendent _______________________________________

Note: To be completed by case and filed in office's file.

To retain for 5 years.

Issue date: 03.11.2003/Rev. 00 PBO-PD03-F03 Page: 1/1

CREW NOT FIT FOR FURTHER WORK ON BOARD

QSMS PBO-PD03-F03 Rev. No.00

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