IDENTIFIED RISK PROPOSAL FORM

IDENTIFIED RISK PROPOSAL FORM                              Consecutive N^o ________

VESSEL

COMPANY

   

Vessel/ Dept.		Date:
Short description of risk identified.
Person(s) and associated ranks dealing with the identified risk reporting.

Frequency (likelihood) may be expressed in terms of:

once per trip            once per ship year           once per fleet year

Consequence may be made more specific by the use of:

first aid injury        serious injury        death       damage to property / environment

RISK = FREQUENCY x CONSEQUENCE

CONSEQUENCE SEVERITY	4	Catastrophic	MEDIUM	HIGH MEDIUM	HIGH MEDIUM	HIGH
	3	Severe	MEDIUM LOW	MEDIUM	HIGH MEDIUM	HIGH MEDIUM
	2	Significant	LOW	MEDIUM LOW	MEDIUM	HIGH MEDIUM
	1	Minor	LOW	LOW	MEDIUM LOW	MEDIUM
			Extremely remote	Remote	Reasonable probable	Frequent
			1	2	3	4
	OCCURRENCE FREQUENCY

Risk level acceptable

Risk level tolerable

Risk level is not tolerable

Person responsible/ rank: ___________________ / _______________

Date form issued: ___________________  Date distribution to Company: _________________

Date form received in Company: ________________

DPA signature: ______________________

The present form must be acknowledged and distributed for proper analyze to qualified personnel; depending on final results the Company will proceed with further amendment of the existing SMS.