CG-11410A (01/18) Marine Transportation System Recovery Facility Status

DEPARTMENT OF HOMELAND SECURITY

U.S. Coast Guard
MARINE TRANSPORTATION SYSTEM RECOVERY
FACILITY STATUS
U.S. Coast Guard

OMB No.1625-0127
Expires: 09/30/2024

is gathering critical facility status information

for the port of

following

.

Information you voluntarily provide will enable the U.S. Coast Guard (USCG) to understand your facility's current status and
will be is used by the USCG Marine Transportation System Recovery Unit to prioritize port-wide recovery efforts.
This is a voluntary solicitation for information and is not mandatory; however, without this information, the USCG cannot
properly assess the condition of your facility and must consider it closed with no critical impact until the USCG is able to
conduct an on-scene assessment.
We request you review the criteria below and provide the information to:
Name

via Fax

via Email

SECTION I: FACILITY INFORMATION
1. Facility Name
2. Facility Status (Check one)
Fully Available

Partially Available

Not Available

3. Describe Reason the Facility is Partially Available or Not Available and at what % capacity the facility is operating and when you anticipate it being fully
available. (i.e. no utility service, channel closure, damage to pier, reduced personnel, damage to facility, cranes, pumps or cyber attack.).

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4. If you do not receive your next scheduled ship/barge on time what is the significant impact? (i.e. your facility supplies the fuel for all city busses or an airport).

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SECTION II: FACILITY CONTACT INFORMATION
5. Facility Point of Contact
CG-11410A (09/21)

6. Telephone

7. Fax

8. Email

9. Date
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MARINE TRANSPORTATION SYSTEM RECOVERY - FACILITY STATUS
Name of Event:

Facility Name:
SECTION 1. FACILITY INFORMATION (Cont.)

PRIVACY ACT STATEMENT
AUTHORITY: 33 U.S.C. §1225; 46 U.S.C. §70103; and 50 U.S.C. §191
PURPOSE: To assess a disruption of Port activities.
ROUTINE USES: Information is used by authorized USCG officials to assess the condition of the Port, prioritize recovery efforts, and gauge the effectiveness of
the response. Any external disclosures of information within this record will be made in accordance with DHS/USCG-013, Marine Information for Safety and Law
Enforcement (MISLE), 74 Federal Register 30305 (June 25, 2009).
DISCLOSURE: Furnishing this information is voluntary; however, the U.S. Coast Guard will not be able to properly assess the condition of the Port without this
valuable input.
An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number.
The Coast Guard estimates that the average burden for this report is 15 minutes. You may submit any comments concerning the accuracy of this burden
estimate or any suggestions for reducing the burden to: Commandant (CG-FAC), U.S. Coast Guard Stop 7318, 2703 Martin Luther King Jr Ave SE,
Washington,DC 20593-7318 or Office of Management and Budget, Paperwork Reduction Project (1625-0127), Washington, DC 20503.

CG-11410A (09/21)

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