ISPS Declaration of Security (DoS) Questionnaire

General Details

Ship Name: IMO Number: Port Facility Name: Port Facility Code: Date: Time From: Time To: Location:

Contact Information

Ship Security Officer (SSO)	Port Facility Security Officer (PFSO)
Name: Contact Number:	Name: Contact Number:

Security Levels

	Ship	Port Facility
Current Security Level

Security Measures to be Implemented

Item	Agreed Measures
1. Monitoring restricted areas
2. Controlling access to ship
3. Controlling access to port facility
4. Escorting visitors/maintenance teams/cargo handling personnel
5. Handling security communications
6. Other Security Measures

Additional Comments

	Ship (Signature & Stamp)	Port Facility (Signature & Stamp)
Name:
Rank/Title:
Signature:
Date: