CHIRP annual digest 2016 6th
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<strong>CHIRP</strong> Maritime<br />
APPENDIX V: <strong>CHIRP</strong> Near Miss report form<br />
Please use the online report available using mobile phone, tablet or personal computer at www.chirpmaritime.org<br />
or by email to reports@chirp.co.uk or using this hand written form.<br />
<strong>CHIRP</strong> Maritime REPORT FORM<br />
<strong>CHIRP</strong> IS TOTALLY INDEPENDENT OF ANY ORGANISATION IN THE MARITIME INDUSTRY<br />
Name:<br />
Address:<br />
PAGE 1 of 2<br />
Telephone Number:<br />
Personal e-mail for reply:<br />
Postcode:<br />
1. <strong>CHIRP</strong> is a reporting programme focussing upon safety related issues in COMPLETE<br />
CONFIDENCE. Your personal details are required only to enable us to contact you for further<br />
details about any part of your report. Please do not submit anonymous reports.<br />
2. On closing this Report, NO RECORD OF YOUR NAME AND ADDRESS WILL BE<br />
KEPT.<br />
On receipt of this report <strong>CHIRP</strong> may seek your approval to contact the owner or manager of<br />
your vessel, or if your report relates to non-compliance with regulations, those of a third party.<br />
The identity of you as the reporter is never disclosed.<br />
On completion of our review, if your report relates to safety issues that may apply generally to<br />
seafarers, it may be considered for publication in MARITIME FEEDBACK. Reports may be<br />
summarised. THE NAME OF THE REPORTER, THE NAMES OF VESSELS AND/OR OTHER<br />
IDENTIFYING INFORMATION ARE NOT DISCLOSED.<br />
PLEASE COMPLETE RELEVANT INFORMATION ABOUT THE EVENT/SITUATION<br />
Date of the incident:<br />
Time (local/GMT):<br />
Your vessel name:<br />
Flag:<br />
IMO number if known:<br />
Vessel type:<br />
(Tanker, bulk carrier, cruise, ferry, fishing, yacht etc)<br />
Vessel location:<br />
Your position onboard or in the organisation:<br />
Please place the completed report form, with additional pages if required, in a sealed envelope to:<br />
The <strong>CHIRP</strong> Charitable Trust, Ancells Business Park, Ancells Road, Fleet, GU51 2UJ, UK<br />
(no stamp required if posted in the UK).<br />
Confidential Tel (24 hrs): +44 (0) 1252 378947 or Freefone (UK only) 0800 772 3243.<br />
Report forms are also available on the <strong>CHIRP</strong> website: www.chirp.co.uk