Rev. No.

: 0
Ocean Jade Shipping Date : 01stJan. 14
CP CHECKLISTS Pre. by : SOT
App. by : DPA

CP CL 03a INITIAL NOTIFICATION REPORT Page 1 of 2

Page 1 of 2
To: Incident:
Date / Time of this report:
AA Vessel Name: Call Sign: Flag:
BB Date/Time: _ _ _ _ /_ _ _ _ / _ _ _ _UTC of the incident (DD/HH/MM)
CC Position Lat: _ _ _ _ _°_ _ _ _ ,_ _ _ _’ N/S Long: _ _ _ _ ° _ _ _ _, _ _ _ _’ E/W
Position: True Bearing: _ _ _ _ _° ; Dist: _ _ _ _. _ _ _nm off (specify
DD
landmark)
EE Course: _ _ _ _ _° (In three digits) FF Speed: _ _ _ _ _. _ _ _ kts (In three digits)

GG II
Last Port: Next Port: ETA :
Radio Stations:
MM
(Give full names of radio Station and frequencies guarded)
NN Time of next report: _ _ _ _ / _ _ _ _ / _ _ _ _ UTC (DD/HH/MM)
OO Maximum Draft: _ _ _ _m _ _ _ _cm (Aft / Forward)

PP Cargo Onboard: (Give U.N. number) (if not applicable attach Cargo Stowage Plan)

QQ Damages/Defects: (Whether or not the ship is seaworthy)

(Brief escription)

RR Description of Incident:

SS Weather Condition: Wind Speed: _ _ _ _ _ (in Knots) Direction: _ _ _ _ _

Swell Speed: _ _ _ _ _ (in Knots) Direction: _ _ _ _ _
TT Ship’s Representative:
(Address and contact numbers)

UU Ship’s type: LOA: (m) Breadth: (m) SDWT:

WW
Persons: Total number persons on board
XX1 Miscellaneous: (The current condition of the ship and other circumstance)

(Actions aken)

(Indicate support required)

Brief details of pollution including; Estimated quantity lost, Technical name UN/IMDG
XX2
Number

XX 3 Any injuries of Fatalities – Name of Crew, What kind injury, Body Part

XX
Do you need shore assistance? – If yes, what kind.
4
 Rev. No. : 0
Ocean Jade Shipping Date : 01stJan. 14
CP CHECKLISTS Pre. by : SOT
App. by : DPA

CP CL 03a INITIAL NOTIFICATION REPORT Page 2 of 2

Page 2 of 2

Master’s Name: Master’s signature: