No: CER/FO/001

EMERGENCY INFORMATION FORMAT Issue No : 02

Rev. No: 00
Page 1 of 1

FOLLOWING INFORMATION MUST BE TAKEN FROM THE CALLING PARTY

 Name of ship Date / Time GMT

 What is your position?

Latitude NORTH/SOUTH Longitude EAST/WEST
OR Miles from
OR PORT Berth No / Anchor

 Weather conditions
Prevailing Forecast Tide / Current

 Nature of Emergency: ( Circle according to what you are told)

EMERGENCY  MESSAGE

Collision with Vessel /
object
Fire ( Location )
Actions taken
Flooding ( which
compartment(s))
Grounding
Pollution
Serious illness
Major injury to person
Piracy / terrorism
Engine breakdown
Steering gear failure
Name / Flag / Port of Registry of other vessel or name of Object
Type of fire: Electrical / Chemical / Normal
If fire in cargo holds:  Total volume of cargo in hold?  How many CO 2 cylinder
using / remain. Actions taken so far
Damage to vessel / location:
Damage to cargo (extent):
Personal injury, or loss of life (specify):
Nature of damage/risk of damage to environment/leakage possibility:
Quantity of oil leakage / Which side (Sea/Shore)?/ Flow overboard / onboard /
Is oil leakage stopped? / Is it still leaking?
Danger of explosion:
Stability problems:
Notified – Agent / Port Authorities / P & I Club / other authorities:
Reason for incident:
ASSISTANCE REQUIRED
Assistance locally available:
Nearest port of refuge:
External assistance required:
Has any Salvor approached vessel?
Any other relevant information:
What actions have been taken?

Man over board

Other (Specify) 

NOTE: Immediately after telephonic notification of Company, this format to be forwarded to EML by Radio Officer/3rd Officer

To be filed in File No. 107