26 SETTLEMENT FOR ACCIDENTS TO AMERICAN SEAMEN

REPORT OF PERSONAL INJURY

IMPORTANT.—An immediate investigation should be held by ship’s officers, of every accident, however slight.
Signed statements of witnesses should be attached to this form. Send this report to the owners withnut
 delay. Report all injuries to crew, stevedores or other persons.

~

Flying what flag
‘ TN ATC eames emssmmmmrmee—e
Address... ..
Age Color Married? How many children?
! ETD ON crimson HHA
Name of nearest relative
Addressee
2.~Date man signed one Where...
3.~~Date crew paid off for current voyage, if known...
4.—Date upon which man was paid offer me
-Before whom.
5.—Wages per month.
6.—(a) In whose employment.
{b) How long employed... —..—...
7.~~Injury received: (a) Date...
(d) To whom first reported...
8—In what port was ip at time of accident...
9.—Deséribe fully how and where the accident happened.

—..Date of Sailing... Voyage Nooo

_ .BRefore whom ooo eo

10.—Describe as fully as possible nature and extent of ininiv