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Name of Vessel:
Visitor / Crew:
It is important for crew to be familiar with each of the following items that are specific to
the operation of this vessel. Please only initial applicable item, to indicate you have
been familiarized and have adequate understanding of its use or procedure.
HSE Policies Review Yes No
HSE Policy
Drug & Alcohol Policy
Stop Work Policy
PPE compliance
HSE Compliance

The location and use of safety and firefighting equipment:

Yes No Yes No
Life raft or internal buoyancy Portable fire extinguisher
Life jackets with lights & whistles Fixed fire suppression & detection
Lifebuoy with light fire hydrant /monitor with hoses
Pyrotechnics Fire buckets with scoop
EPIRB Vent closures / fuel shut offs
First aid equipment and First Signage’s and Water tight doors

The routine operation, procedure or general knowledge of:

Yes No Yes No
Windlass / anchoring Watch keeping responsibilities
Preparing vessel for sea Bunkering
Berthing / mooring lines Fishing equipment & safety
Wheel / engine controls & pilot Communication equipment
Electrical & emergency control General House keeping
Bilge & tank pumping Garbage / oil / sewage disposal
Hatches and closures Record keeping
Navigational equipment Incident reporting

The response in the event of an emergency:

Yes No Yes No
Heavy Weather Damage Search and Rescue
Fire / Explosion Man Over Board
Collision Hull Failure
Main Engine Failure Abandon Ship
Flooding / grounding / Stranding Steering failure
Oil Spill / Pollution Terrorism / Sabotage/ Piracy
Acknowledgement of instruction provided by the master / owner and received by the crew for those items
initialed above
Signature & Date
Name of Crew
Name of Vessel Master Signature/Stamp
& Date

Date: 18-Nov-13 KMS-HSE-FRM-008 Rev.B

Name of Emergency Contact for Phone
crew (Next of Kin)

Yes: Familiarized with adequate understanding NO: Not

Familiarized with and no understanding. N/A: Not required

Date: 18-Nov-13 KMS-HSE-FRM-008 Rev.B