Ship Shore Safety Checklist Form
Complete this checklist to verify ship and shore safety conditions prior to operations.
Vessel Name
*
Date of Inspection
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Responsible Officer
*
First Name
Last Name
Safety Equipment Checked and Ready
*
Yes
No
Not Applicable
Communication Systems Operational
*
Yes
No
Not Applicable
Emergency Procedures Briefed
*
Yes
No
Not Applicable
Access/Egress Routes Clear
*
Yes
No
Not Applicable
Hazards Identified (if any)
Corrective Actions Taken (if applicable)
Inspection Status
*
Completed
Incomplete
Requires Follow-up
Inspector's Signature
*
Submit Checklist
Submit Checklist
Should be Empty: