Description of accident or dangerous occurrence in words: Accident classification code Dangerous Occurrence classification code Did accident or dangerous occurrence occur during normal Normal O/Time working hours or overtime? Did accident or dangerous occurrence happen at normal Y N workplace? Average number of persons at work during SURF OPS U\G O/CAST SURF MIN MARINE the previous month SECTION C: RESPONSIBLE PERSONS Name Identity Number/Passport Certificate No. Occupation Number 1st Level Supervisor 2nd Level Supervisor
Description of accident or dangerous occurrence in words: Accident classification code Dangerous Occurrence classification code Did accident or dangerous occurrence occur during normal working hours or overtime? Normal O/Time Did accident or dangerous occurrence happen at normal workplace? Y N Average number of persons at work during the previous month SURF OPS U\G O/CAST SURF MIN MARINE SECTION C: RESPONSIBLE PERSONS Name Identity Number/Passport Number Certificate No. Occupation 1st Level Supervisor 2nd Level Supervisor
dmr_217_samrass_01_accident_and_dangerous_occurrence_report_form.docx