Maritime Environmental Incident Notification Form

Reporter Details

Full Name Organisation/Agency Contact Information (Phone/Email)

Incident Details

Date of Incident Time of Incident Location (Coordinates or Description) Type of Incident Oil Spill Chemical Spill Garbage/Debris Ballast Water Other Description of Incident

Vessel / Source Information

Vessel Name (if applicable) Vessel Type Flag State

Additional Information

Immediate Actions or Measures Taken Other Agencies Notified Remarks/Comments