Crew Complaint Form

Crew Complaint Form
(Formulir Keluhan Crew)
Name of Ship: IMO Number:

(Nama Kapal) (Nomor IMO)
Number of Complaint:
(Nomor Keluhan)
All parts of this form must be filled by the Fleet Manager/Operator in the shortest time possible. This form, once filled, is
confidential and can’t be disseminated outside the office without complaining seafarer’s approval.
(Semua bagian dari Form ini harus diisi secara tepat dan secepatnya oleh setiap Crew. Semua data dalam Form ini bersifat rahasia
dan tidak dapat disebarluaskan tanpa persetujuan Crew yang bersangkutan)
Name of the complaining seafarer: ______________________________

(Nama Crew)
Vessel, if onboard or last vessel, if ashore ______________________________

(Nama Kapal)
Date of complaint: ______________________________

(Tanggal Keluhan)
Reason form complaint: ___________________________________________________________

(Alasan Keluhan)
_______________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Briefly describe your complaint. If more space is needed please attach additional
pages.
(Jelaskan secara rinci mengenai keluhan yang diadukan, tambahkan halaman jika halaman yang
tersedia tidak mencukupi)
1
FRM-MLC-D0000-PKG-CRW-10-01, Rev.0
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CONTACT INFORMATION
(Informasi Kontak)
Contact information of the Crew Agent

(Informasi Kontak PT.PETEKA KARYA GAPURA)
Name: 1. Suwarta
(Nama) 2. Andika Yudistira
3. Adek Febriyandi
Position: Staff Crewing

(Jabatan)
Address: Jl. Yos Sudarso Kav. 205 Sunter – Tanjung Priok, Jakarta Utara
(Alamat)
Telephone: 021- 65307030-31 dan 41

(Telepon)
Handphone: 1. Suwarta : 081311352931

2. Andika Yudistira: 081310302949
3. Adek Febriyandi: 085721123706
Email: 1. Adek Febriyandi: [email protected]
2
Contact information of the Shipowner
(Informasi Kontak PT.PERTAMINA TRANS KONTINENTAL)
Name: Darwanto
(Nama)
Position: Assistant Manning

(Jabatan)
Address: Jl. Kramat Raya No.9 – Kramat, Jakarta Pusat

(Alamat)
Telephone: 021- 31923005, Handphone 081387071222

(Telepon)
Email: [email protected]
Name of designated person/persons on board to provide crew members on a confidential

basis with impartial advice on their complaint and to assist them in the course of the
complaint procedure
(Personil yang ditunjuk untuk membantu Crew dalam menangani keluhan/Pemberi Saran)
Name:
(Nama)
Rank:
(Jabatan)
(Nama Diisi dengan nama Nahkoda Kapal)
Contact information of the competent flag state authority

(Informasi kontak otoritas negara asal kapal)
Name:
(Nama)
Address:
(Alamat)
Contact Person:
(Penanggung Jawab)
Telephone:
(Telepon)
Email:
(Diisi sesuai dengan rute pelayaran kapal)
3
Contact information of the competent authority in the crew members' country of
residence
(Kontak informasi perwakilan negara/Kantor Kedutaan tempat Crew bekerja)
Name:
(Nama)
Address:
(Alamat)
Contact Person:
(Penanggung Jawab)
Telephone:
(Telepon)
Email:
(Diisi sesuai dengan rute pelayaran kapal)
Seafarer’s interview: Yes No
Have you followed the Manager’s complaint procedure?  

(Apakah anda telah mengikuti prosedur keluhan kepada atasan langsung?)
Have you got an answer from Manager’s on board complaint procedure?  

(Apakah anda mendapat solusi terkait keluhan dari atasan langsung di kapal?)
If yes to previous question: are you satisfied with the answer?  

(Jika Ya: apakah anda puas dengan solusi yang diberikan?)
If no to previous question: Why are you not satisfied?  

(Jika Tidak: mengapa anda merasa tidak puas?)
May we extend you complaint to the ship’s Manager?  

(Apakah kami dapat meneruskan keluhan anda kepada Nahkoda/PKG?)
Other ship’s staff interview:

(Wawancara/dengar pendapat dengan Crew lain)
Name: __________________________ Rank: _____________________________

(Nama) (Jabatan)
Declarations:
(Penjelasan)
______________________________________________________________________
______________________________________________________________________
Office outcome
(Solusi PT.PETEKA KARYA GAPURA)
4
Office option for complaint solving: __________________________________________________________
(Solusi pemecahan keluhan)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Has the seafarer declared to be satisfied by the proposed solution?  Yes  No

(Apakah Crew puas dengan penawaran solusi yang diajukan)
The Complaint has been  resolved /  unresolved

(Keluhan telah selesai / belum selesai)
If unresolved, explain reasons: ______________________________________________________________________

(Jika belum selesai, jelaskan alasannya)
________________________________________________________________________________________________
________________________________________________________________________________________________
PENTING UNTUK DIPERHATIKAN
1) Crew harus menyampaikan keluhan secepatnya atau dalam waktu maksimal 5 (lima) hari setelah
kejadian, dengan penyampaian keluhan secara berjenjang :
a. Atasan Langsung
b. Nahkoda/Kapten
c. PT. PETEKA KARYA GAPURA atau Pemilik Kapal/User
2) Keluhan diusahakan diselesaikan pada level terendah, dan hanya dapat disampaikan kepada
Nahkoda/Kapten atau ke jenjang yang lebih tinggi (PT. PETEKA KARYA GAPURA atau Pemilik Kapal/User)
apabila solusi keluhan dianggap belum memuaskan.
3) PT. PETEKA KARYA GAPURA atau Pemilik Kapal/User dan Crew berkoordinasi untuk menangani keluhan
dan diusahakan dapat diselesaikan dalam waktu 20 (dua puluh) hari.
4) Apabila keluhan belum diselesaikan dalam waktu 20 (dua puluh) hari, maka dapat diperpanjang 20 (dua
puluh) hari berikutnya.
5) Salinan keluhan disampaikan kepada Crew yang bersangkutan, semua keluhan dan keputusan bersifat
rahasia.
Disusun oleh Diperiksa oleh Disetujui oleh
5

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Crew Complaint Form

(Formulir Keluhan Crew)

Name of Ship: IMO Number:

Name of the complaining seafarer: ______________________________

Vessel, if onboard or last vessel, if ashore ______________________________

Date of complaint: ______________________________

Reason form complaint: ___________________________________________________________

Contact information of the Crew Agent

Position: Staff Crewing

Telephone: 021- 65307030-31 dan 41

Handphone: 1. Suwarta : 081311352931

Email: 1. Adek Febriyandi: [email protected]

Position: Assistant Manning

Address: Jl. Kramat Raya No.9 – Kramat, Jakarta Pusat

Telephone: 021- 31923005, Handphone 081387071222

Name of designated person/persons on board to provide crew members on a confidential

(Nama Diisi dengan nama Nahkoda Kapal)

Contact information of the competent flag state authority

(Diisi sesuai dengan rute pelayaran kapal)

(Diisi sesuai dengan rute pelayaran kapal)

Seafarer’s interview: Yes No

Have you followed the Manager’s complaint procedure?  

Have you got an answer from Manager’s on board complaint procedure?  

If yes to previous question: are you satisfied with the answer?  

If no to previous question: Why are you not satisfied?  

May we extend you complaint to the ship’s Manager?  

Other ship’s staff interview:

Name: __________________________ Rank: _____________________________

Has the seafarer declared to be satisfied by the proposed solution?  Yes  No

The Complaint has been  resolved /  unresolved

If unresolved, explain reasons: ______________________________________________________________________

PENTING UNTUK DIPERHATIKAN

Disusun oleh Diperiksa oleh Disetujui oleh

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