Cruise Line Health Incident Report Form
Please use this form to report any health-related incidents that occur onboard. Complete all sections to ensure a thorough and accurate report.
Incident Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident (Deck, Area, etc.)
*
Full Name of Person(s) Affected
*
First Name
Last Name
Role of Person(s) Affected
*
Please Select
Passenger
Crew Member
Visitor
Other
Type of Incident
*
Please Select
Injury
Illness
Food-related
Other
Describe the Incident in Detail
*
Symptoms Observed (if applicable)
Fever
Cough
Shortness of Breath
Nausea/Vomiting
Diarrhea
Rash
Other
Actions Taken (First Aid, Isolation, Medical Attention, etc.)
*
Were there any witnesses?
*
Yes
No
If yes, please provide witness name(s) and contact details
Name of Staff Reporting the Incident
*
First Name
Last Name
Contact Phone Number of Reporting Staff
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Report
Should be Empty: