Pollution Discharge Reporting Form (Shipboard)
Ship Information
Ship Name
IMO Number
Flag State
Incident Details
Date & Time of Incident
Location (Latitude / Longitude)
Area / Port
Pollution Details
Type of Pollutant
Oil
Chemical
Sewage
Garbage
Other
Quantity Discharged (approx.)
Source of Discharge
Circumstances / Cause
Action Taken
Reported By
Name
Rank / Position
Date