Annex 4B – Survey Planning Questionnaire

The following information will enable the owner, in cooperation with the Administration, to develop a survey programme complying with the requirements of the Code. It is essential that the owner provides, when completing the present questionnaire, up-to-date information. The present questionnaire, when completed, will provide all the information and material required by the Code.

1 Particulars

Ship's name:

IMO number:

Flag State:

Port of registry:

Owner:

Recognized organization:

RO Ship identity:

Gross tonnage:

Deadweight (metric tonnes):

Date of build:

2 Information on access provision for close-up surveys and thickness measurement

The owner shall indicate, in the table below, the means of access to the structures subject to close-up survey and thickness measurement. A close-up survey is an examination where the details of structural components are within the close visual inspection range of the attending surveyor, i.e. normally within reach of hand.

Hold/Tank No.	Structure	Permanent means of access	Temporary staging	Rafts	Ladders	Direct access	Other means (please specify)
F.P.	Fore peak
A.P.	Aft peak
Cargo holds	Hatch side coamings
	Topside sloping plate
	Upper stool plating
	Cross deck
	Double-side tank plating
	Transverse bulkhead
	Hopper tank plating
	Lower stool plating
	Tank top
Topside tanks	Under-deck structure
	Side shell and structure
	Sloping plate and structure
	Webs and bulkheads
Hopper tanks	Hopper sloping plate and structure
	Side shell and structure
	Bottom structure
	Webs and bulkheads
Double-side tanks	Side shell and structure
	Inner skin and structure
	Webs and bulkheads
	Double-bottom structure
	Upper stool internal structure
	Lower stool internal structure
Wing tanks of ore carriers	Underdeck and structure
	Side shell and structure
	Side shell vertical web and structure
	Longitudinal bulkhead and structure
	Longitudinal bulkhead web and structure
	Bottom plating and structure
	Cross ties/stringers

History of bulk cargoes of a corrosive nature (e.g. high-sulphur content)

3 Owner's inspections

Using a format similar to that of the table below (which is given as an example), the owner shall provide details of the results of their inspections, for the last three years in accordance with the Code on all CARGO holds and BALLAST tanks and VOID spaces within the cargo area.

Tank/Hold No.	Corrosion protection (1)	Coating extent (2)	Coating condition (3)	Structural deterioration (4)	Hold and tank history (5)
Cargo holds
Topside tanks
Hopper tanks
Double-side skin tanks
Double-bottom tanks
Upper stools
Lower stools
Wing tanks (ore tankers)
Fore peak
Aft peak
Miscellaneous other spaces:

*Note:*

Indicate tanks which are used for oil/ballast.
1)	HC = hard coating; SC = soft coating;
	SH = semi-hard coating; NP = no protection
2)	U = upper part; M = middle part;
	L = lower part; C = complete
3)	G = good; F = fair; P = poor;
	RC = recoated (during the last three years)
4)	N = no findings recorded; Y = findings recorded,
		description of findings should be attached to this questionnaire
5)	DR = damage & repair; L = leakages;
	CV = conversion (description to be attached to this questionnaire)

Reports of port State control inspections

List the reports of port State control inspections containing hull structural related deficiencies, and relevant information on rectification of the deficiencies:

Safety management system

List non-conformities related to hull maintenance, including the associated corrective actions:

Name and address of the approved thickness measurement firm