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Maritime Security Incident Report Online Form

A completed report submitted to the Department of Infrastructure, Transport, Regional Development and Local Government using this form will fulfil incident reporting obligations under Part 9 of the Maritime Transport and Offshore Facilities Security Act 2003 (MTOFSA).

This form may be used to assist in making reports to police and other Maritime Industry Participants (MIPs) or Offshore Industry Participants (OIPs).

An incident under Part 9 of the MTOFSA must be reported in writing to the Department as soon as possible. The Department should be notified within 4 hours of the MIP becoming aware of the incident, and the written report should be provided within 72 hours.

PART 1 - Type of Incident

Maritime Transport or Offshore Facility Security Incident
(s. 170 of the MTOFSA)

Other Maritime Security Event

PART 2 - Incident Details

Name of MIP/OIP affected:
Location of incident:
Date:
Time:	:

MIP type (please specify):
	Port operator	Ship operator
	Port facility operator	Other
	Offshore facility operator
If Other Please Specify:

Nature of Incident:
	Threat	Extortion
	Hijack	Hoax
	Suspicious activity	Interference with equipment/ facilities
	MSIC or other ID card	Unauthorised access to a security zone
	Failure of a screening point	Serious bodily harm / death
	Unauthorised disclosure of a security plan	Unauthorised weapons/prohibited items
	Sabotage	Theft
	Vandalism	Other
If Other Please Specify:
If applicable, provide name of person / organisation who notified you of this incident:

PART 3 - Ship Details (if applicable and if known) Check box if unknown or not applicable

Ship's name:
IMO no.:		ISSC no.:
Type:		Size:
Type of Cargo:
Flag:

PART 4 - Building/Structure Identifier (if applicable and if known) Check box if unknown or not applicable
Insert building number or other identifier

PART 5 - Incident Narrative and response taken

PART 6 - Other MIPs / OIPs involved

Other Parties involved:

PART 7 - Has the incident been previously reported to the Department's OTS Operations Centre?

Yes	No
If Yes, please fill in approximate date/time the Department was notified.
Date: Time:	:

PART 8 - If applicable, has the incident been reported to:

State/Territory Police?	Yes	No
Affected MIPs/OIPs identified in Part 6 above?	Yes	No
If No, please report the incident to those parties in accordance with Part 9, Division 4 of the MTOFSA.

PART 9 - Details of person completing report
Name:
Position:
Employer:

PART 10 - Other Relevant Information

Timesaver (Time taken to complete form):

hrs minutes

Purpose of submitting Report Form
	Notification	Purpose of submitting this form is to notify the Department's OTS Operations Centre of a maritime transport security incident or other maritime security event.
	Report	Purpose of submitting this form is to provide a report of a maritime transport security incident or other maritime security event.

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Last Updated: 24 July, 2008