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Incident / Defect Report Form

This form is to be used to notify Weymouth Harbour of an incident, accident or notification of a defect within the Harbour.

The report should be completed following a safety and or navigation accident.

* = required field. In sections 5–7 the required fields only apply if you have selected the relevant type of incident in section 3.

1. Personal Details (person reporting incident)
Name/Title/Rank *
Please enter a name.
Occupation
Address
Phone number *
Please enter a phone number.
Email *
Please enter an email address.
Witness (if applicable)
Details of any injuries (if applicable)
2. Vessel Information
Vessel Name
IMO Number (if applicable)
Operator Name / Company
Responsible Person (if known)
Contact Details
Vessel Type
Vessel Length / Beam / Draught
Vessel Activity at time of incident
Pilot on board
Cargo on board
Cargo type
Destination Port (if applicable)
3. Incident Details
Date *
Please enter a date.
Time *
Please enter a time.
Location (lat/long if known) *
Number of persons on board
Crew
Passengers
Others
Weather
Visibility
What Happened? *
Not required if 'Defects' is selected as type of incident below
Please describe what happened.
What were the causes?
Type of Incident *
Please select an incident type.
4. Oil Spill / Polution Report
Type of pollution
Cause of pollution
Estimated amount of pollutant spilled
Geographic extent of pollution
Fuel grade
Immediate Actions Taken
Other authorities contacted (who / time)
Type of response equipment used
Extent of any damage to vessel
5. Accident Report
Person reporting the accident
Name/Title/Rank *
Please enter a name.
Occupation
Address
Person involved / all affected persons
Name/Title/Rank
Occupation
Address
About the accident *
Please describe the accident.
Injuries Sustained
E-signature
6. Potential Risk Report
Name *
Please enter a name.
Address
Email *
Please enter an email address.
Phone number *
Please enter a phone number.
Details of risk
Date *
Please enter a date.
Time *
Please enter a time.
Location *
Please enter a location.
Weather / Tide
Description of Risk
7. Defect Report
Name of person reporting defect
Date *
Please enter a date.
Location *
Please enter a location.
Description of defect
8. Actions Taken
Please state what has been done to prevent this accident from re-occurring?
9. Additional Comments
Additional comments