Ballast Water Reporting Form

* - denotes a required field.

1. Vessel Information

*Vessel: *Vessel Type:
*Owner: *IMO Number:
*GT: *Call Sign:
*Flag: *Arrival Date:
(dd/mm/yyyy)
*Agent: *Last Port / Country:
*Arrival Port: *Next Port / Country:

2. Ballast Water

Total Ballast Water On-Board:
Total Ballast Water Capacity:

3. Ballast Water Tanks

Is There a Ballast Water Management Plan On-Board?
Has the Plan Been Implented?
Total Number of Tanks On-Board:
Number of Tanks In Ballast:
If 'none', go to Section 5.
Number of Tanks Exchanged:
Number of Tanks Not Exchanged:

4. Ballast Water History

Record All Tanks That Will Be De-Ballasted in Port State of Arrival.

If 'none', go to Section 5.

Ballast Water Source

Tanks / Holds Date (dd/mm/yyyy) Port or Lat. Long Volume (units) Temp (units)

Ballast Water Exchange

Choose one:
Tanks / Holds Date (dd/mm/yyyy) Endpoint Lat. Long Volume (units) % Exch. SEA Hgt.(m)

Ballast Water Discharge

Tanks / Holds Date (dd/mm/yyyy) Port or Lat. Long Volume (units) Salinity (units)
If Exchanges Were Not Conducted, State Other Control Actions Taken:
If No Other Actions Taken, State Reason Why Not:

5. IMO Ballast Water Guidelines

Are There Ballast Water Guidelines On-Board (Res.868(20))?

* - denotes a required field.

*Resp. Officer's Name / Title:
*Date:
(dd/mm/yyyy)