1

Vessel name

2

Flag (if applicable)

3

IMO Number (if applicable)

4

Unique identifier (if applicable)

5

Master

6

Operator or company name

7

Responsible person

8

Contact details

9

If the vessel is a Domestic Commercial Vessel:

(a) class; and

(b) operational area

10

The following details of the incident:

(a) the date;

(b) the time (local and UTC);

(c) the voyage start and finish point;

(d) a description of the location of the incident;

(e) the latitude and longitude of the incident

11

Which of the following vessel activities were being undertaken at the time of the incident:

(a) underway;

(b) berthing/unberthing;

(c) berthed;

(d) towing;

(e) anchored;

(f) fishing/unloading;

(g) loading/unloading;

(h) being towed;

(i) other (specify)

12

Whether a pilot was on board

13

Whether cargo was on board

14

Any of the following consequences:

(a) injury;

(b) illness;

(c) death;

(d) medical evacuation;

(e) man overboard without a lifejacket;

(f) man overboard wearing a lifejacket;

(g) presumed loss of a person;

(h) equipment/machinery failure;

(i) damage;

(j) loss of cargo/dangerous goods;

(k) leakage/spillage of dangerous goods;

(l) contact with something other than a vessel;

(m) collision with another vessel;

(n) MARPOL issues;

(o) fire/smoke;

(p) grounding;

(q) disabled;

(r) foundering/sinking;

(s) flooding;

(t) near miss/dangerous occurrence;

(u) other (specify)

15

A description of the incident