App. 13 – PSC Report of Inspection Guidelines

REPORT OF INSPECTION IN ACCORDANCE WITH
PROCEDURES FOR PORT STATE CONTROL*

FORM A

(Reporting authority) Copy to: Master
(Address) Head office
(Telephone) PSCO
(Telefax)
(Email)

If ship is detained, copy to:
Flag State
IMO
Recognized organization, if applicable

1 Name of reporting authority ………………… 2 Name of ship …………………………………….

3 Flag of ship ……………………………………… 4 Type of ship ……………………………………..

5 Call sign ………………………………………….. 6 IMO number ……………………………………..

7 Gross tonnage …………………………………. 8 Deadweight (where applicable) ……………

9 Year of build …………………………………….. 10 Date of inspection ……………………………..

11 Place of inspection ……………………………. 12 Classification society ………………………….

13 Date of release from detention** …………..

14 Particulars of ISM company (details or IMO Company Number)** …………………………………….

15 Contact information of financial security provider …………………………………………………………..
Expiry date*** ………………………………………………………………………………………………………………

16 Relevant certificate(s)**

a) Title b) Issuing authority c) Dates of issue and expiry

1 ………… ……………………… …………………………………. ……………………………………
2 ………… ……………………… …………………………………. ……………………………………
3 ………… ……………………… …………………………………. ……………………………………
4 ………… ……………………… …………………………………. ……………………………………
5 ………… ……………………… …………………………………. ……………………………………
6 ………… ……………………… …………………………………. ……………………………………
7 ………… ……………………… …………………………………. ……………………………………
8 ………… ……………………… …………………………………. ……………………………………
9 ………… ……………………… …………………………………. ……………………………………
10 ………… ……………………… …………………………………. ……………………………………
11 ………… ……………………… …………………………………. ……………………………………
12 ………… ……………………… …………………………………. ……………………………………

d) Information on last intermediate or annual survey**

Date Surveying authority Place

17 Deficiencies No Yes (see attached FORM B)

18 Penalty imposed No Yes Amount:

19 Ship detained No Yes ****

20 Supporting documentation No Yes (see annex)

Issuing office ………………………………………. Name ………………………………………………
(duly authorized PSCO of reporting
authority)

Telephone …………………………………….. Email ………………………………………

Telefax ……………………………………………… Signature …………………………………………

This report must be retained on board for a period of two years and must be available
for consultation by port State control officers at all times.
________________

* This inspection report has been issued solely for the purposes of informing the master and other port States
that an inspection by the port State, mentioned in the heading, has taken place. This inspection report cannot
be construed as a seaworthiness certificate in excess of the certificate the ship is required to carry.
** To be completed in the event of a detention.
*** As required by regulations 2.5 and 4.6 of MLC 2006.
**** Masters, shipowners and/or operators are advised that detailed information on a detention may be subject
to future publication.

REPORT OF INSPECTION IN ACCORDANCE WITH
PROCEDURES FOR PORT STATE CONTROL

FORM B

(Reporting authority) Copy to: Master
(Address) Head office
(Telephone) PSCO
(Telefax)
(Email)

If ship is detained, copy to:
Flag State
IMO
Recognized organization, if applicable

2 Name of ship ……………………………………. 6 IMO number ………………………………………

10 Date of inspection …………………………….. 11 Place of inspection ……………………………..

21 Nature of deficiency¹ Convention² 22 Action taken³ 23 ISM-related
………………… ………………… ………………… …………….
………………… ………………… ………………… …………….
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………………… ………………… ………………… …………….
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Name ………………………………………………
(duly authorized PSCO of reporting
authority)

Signature ………………………………………..

¹ This inspection was not a full survey and deficiencies listed may not be exhaustive. In the event of a
detention, it is recommended that a full survey is carried out and all deficiencies are rectified before an
application for re-inspection is made.
² To be completed in the event of a detention.
³ Actions taken include ship detained/released, flag State informed, classification society informed, next port
informed.