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Run: Cruise Ship Maritime Injury and Near Miss Report Form

Document crew injuries and near misses on board a cruise ship with a clear, maritime-specific report form. Capture the incident, medical response, witnesses,...

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Submission Notice

Report type (required)

Data use and disclosure notice

By submitting this form, you consent to the collection and use of incident details, including limited PII if provided, for safety investigation, corrective action, and reporting determination. Only authorized personnel will access the audit trail and submission record.

Anonymous submission

Select this if you want to submit without your name. Anonymous submissions may limit follow-up and corrective action tracking.

Yes No N/A

Incident Overview

Date of incident (required)

Time of incident (required)

Vessel name (required)

Voyage, port, or itinerary segment

Enter the voyage number, port name, or itinerary segment where the incident occurred.

Exact location on vessel (required)

Examples: galley, engine room, stairwell, cabin corridor, embarkation deck.

Brief incident summary (required)

Affected Person

Affected person role (required)

Department or function

Job title or role

Did an injury occur? (required)

Type of injury

Shown only if an injury occurred.

Incident Details

Incident category (required)

Activity being performed (required)

Immediate cause or unsafe act/condition (required)

Contributing factors

Select all factors that may have contributed to the incident.

Immediate action taken

Injury or Medical Response

Was medical attention required? (required)

Treatment provided

Expected lost time

Reporting, Witnesses, and Corrective Action

Were there witnesses? (required)

Witness details

Add one row per witness. Collect only what is needed for follow-up.

Reporting determination

Select any reporting pathways that may apply. Final determination should be made by the safety or compliance team.

Corrective action assigned

Follow-up owner

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Email (required)

Your name (optional)

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