Exclusion Assessment Form
In accordance with IACS UR E26 Section 6 – Risk-Based Exclusion
Doc ID: TAG-EXCL-2026
Version: 1.1
Version: 1.1
1. SYSTEM UNDER ASSESSMENT
| System Name: | |||
| Manufacturer: | Location: | ||
2. COMPLIANCE CHECKLIST
| Isolation: No physical or logical connection to Cat II or III systems? | [ ] YES |
| Safety: Compromise cannot affect propulsion, steering, or power? | [ ] YES |
| Environment: Compromise cannot cause a MARPOL discharge? | [ ] YES |
| Regulations: Exempt from SOLAS, MARPOL, and Class rules? | [ ] YES |
| Maintenance: Access is physically controlled or air-gapped? | [ ] YES |
3. TECHNICAL JUSTIFICATION
Detail the evidence for exclusion (e.g., “Physically isolated LAN,” “Non-essential bus,” etc.)
Owner Representative:
Signature & Date
Class Surveyor Acceptance:
Stamp, Signature & Date