Port State Control
Environmental Incident Statement
1. Vessel Information
Name of Ship
IMO Number
Flag State
Call Sign
2. Incident Information
Date of Incident
Time of Incident (UTC)
Latitude
Longitude
Port / Location
Details of Area (Berth, Anchorage, etc.)
3. Description of Incident
Nature of Incident
Type of Pollutant / Substance
Estimated Quantity Released
Cause of Incident
Immediate Action Taken
4. Authorities Informed
Name(s) of Authority/Authorities Informed
Time Informed
5. Additional Information
Other Relevant Information
6. Declaration
Name of Master / Responsible Person
Rank / Position
Date