Vessel Collision Pollution Damage Report
1. Incident Details
Date of Incident
Time of Incident
Location
Description of Incident
2. Vessel Information
Vessel 1 Name
IMO Number
Vessel 2 Name
IMO Number
3. Pollution Details
Type of Pollutant
Estimated Quantity Released
Area Affected
Description of Pollution Damage
4. Action Taken
Immediate Action Taken
5. Reporting Party
Name
Role/Position
Organization
Contact Information