FEDERAL COMMUNICATIONS COMMISSION Approved by OMB

 3060-0228

 Estimated Time Per Response: 10 Minutes

 

United States of America

CERTIFICATE OF COMPLIANCE WITH THE RADIO PROVISIONS OF THE INTERNATIONAL 

CONVENTION FOR THE SAFETY OF LIFE AT SEA, 1974 (AS AMENDED)

 

Name of Ship Official 

Number

Radio 

Call Sign

Port of Registry Gross 

Tonnage

 

Officer in Charge, Marine Safety Office,

United States Coast Guard,

This is to inform you that the above-described ship was inspected at _________________________________

_____________________________________ on ____________________, 19________ by an FCC licensed techni cian and was 

found to comply with the radio provisions of the internal Convention for the Safety of Life at Sea, in force.

 It is desired that an appropriate certificate concerning the radio particulars, as provided in the Convention, be 

issued on behalf of this vessel. This certificate should include the following entries:

DETAILS OF RADIO FACILITIES

 Item Actual Provision

1. Primary systems:..................................................................................

1.1 VHF radio installation:............................................................................

1.1.1 DSC encoder:....................................................................................... 

1.1.2 DSC watch receiver:.............................................................................. 

1.1.3 Radiotelephony:.................................................................................... 

1.2 MF radio installation:..............................................................................

1.2.1 DSC encoder:....................................................................................... 

1.2.2 DSC watch receiver:.............................................................................. 

1.2.3 Radiotelephony:.................................................................................... 

1.3 MF/HF radio installation:.........................................................................

1.3.1 DSC encoder:....................................................................................... 

1.3.2 DSC watch receiver:.............................................................................. 

1.3.3 Radiotelephony:.................................................................................... 

1.3.4 Direct printing radiotelegraphy:.................................................................

1.4 INMARSAT ship earth station:.................................................................. 

2. Secondary means of alerting:...................................................................

3. Facilities for reception of maritime safety information:..................................

3.1 NAVTEX receiver:................................................................................ 

3.2 EGC receiver:...................................................................................... 

3.3 HF direct printing radiotelegraph receiver:.................................................

4. Satellite EPIRB:...................................................................................

4.1 COSPAS-SARSAT:..............................................................................

4.2 IMMARSAT:........................................................................................

5. VHF EPIRB:........................................................................................

 

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 FCC Form 806 – Page 1

 August 2012
Approved by OMB

 3060-0228

DETAILS OF RADIO FACILITIES (Continued)

 Item Actual Provision

6. Ship’s radar transponder:.......................................................................

7. Radiotelephone distress frequency watch receiver on 2182 kHz (until 1 Feb. 

1999)............................................................................................................

8. Device for generating the radiotelephone alarm signal on 2182 kHz (until 1 Feb. 

1999)............................................................................................................ 

 Methods used to insure availability of radio facilities (Reg. IV/15.6 & 15.7)

1. Duplication of equipment:...................................................................... 

2. Shore-based maintenance:.................................................................... 

3. At-sea maintenance capability:............................................................... 

 Ships constructed before 1 February 1995 which do not comply 

 with all the applicable requirements of Chapter IV of the 

 Convention as amended in 1988 (until 1 February 1999)

1. Hours of listening by operator:...............

2. Number of operators:........................... 

3. Whether auto alarm fitted:..................... 

4. Whether main installation fitted:..............

5. Whether reserve installation fitted:.......... 

6. Whether main and reserve transmitters

 electronically separated or combined:...... 

 Ships constructed before 1 February 1995 which do not fully

 comply with all the applicable requirements of Chapter IV of the 

 Convention as amended in 1988 (until 1 February 1995)

1. Radiotelegraph installation for lifeboat:...................................................

2. Portable radio apparatus for survival craft:..............................................

3. Survival craft EPIRB (121.5 MHz and 243.0 MHz):....................................

4. Two-way radiotelephone apparatus:......................................................

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 Inspection made by or under the direction of:

COMPANY NAME

INSPECTOR SIGNATURE

 FCC Form 806 – Page 2

 August 2012

Requirements of regulations

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OMB Control Number 3060-0228

Notice to Individuals Required by the Privacy Act of 1974 and the Paperwork Reduction Act of 1995

The solicitation of information requested in this form is authorized by th e Communications Act of 1934, as amended. The 

Commission will use FCC-licensed technicians to conduct ship inspections and determine if the radio installation is in compliance

with the requirements of the Communications Act of 1934, as amended. All information provided in this form, as well as the form 

itself, will be available for public inspection.

Public reporting burden for this collection of information is estimated to average 10 minutes per response. Our estimate includes the 

time to read the instructions, look through existing records, gather and maintain required data, and actually complete and review the 

form or response. If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it 

causes you, please write the Federal Communications Commission, Office of Managing Director, AMD-PERM, Washington, DC 

20554, Paperwork Reduction Act Project (3060-0228). We will also accept your PRA comments via the internet if you sent an email to PRA@fcc.gov.

Please DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. You are not required to respond to a collection of information 

sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently 

valid OMB control number and/or we fail to provide you with this notice. This collection has been assigned an OMB control number 

of 3060-0228.

THIS NOTICE IS REQUIRED BY THE PRIVACY ACT OF 1974, PUBLIC LAW 93-579, DECEMBER 31,1974, 5 U.S.C. SECTION 

552a(e)(3) AND THE PAPERWORK REDUCTION ACTION OF 1995, PUBLIC LAW 104-13, OCTOBER 1,1995, 44 U.S.C. 

SECTION 3507.

 FCC Form 806 – Page 3

 August 2012