REGULATIONS AFFECTING SEAMEN

25

tL. (a) Was the men perfectly sober? ........ccc....... (8) Was ho careless? ....oooooooooooooeeo oo.
(¢) Was any other person at fault? If so, who and in what way? oo...

ht 4 mm

12. What was dono for man after accident, with name and address of attending physician and hospital, if any ?

13. Diagmosia ___._____

14. Was man able to return to duty? ..coeeoeoeoo. If 80, When ooo
15. State probable period of disablement «...:..oooooeeoeoeoeoee

16. Give statement, if any, made by jnjured person

17. Remarks: o.oo.

Names of witnesses to accident, persons assisting in
work. and thore nearhir

Addresses

0 0 AB 8 TR A MA

GSlematre of Masters tre of Senay TTT meses essa onan

Date oes DRS meee. Date ee