E.N. Bisso & Son, Inc. Master’s Incident Form Number: 03-15 Responsible Carrier Report Program Form Revision Date: 09/15/07

The Master’s Incident Report is used by the Master to report any incident during his/her duty cycle. All incidents are to be reported using this report form, regardless of the severity of the incident. Incidents include injury, collision, grounding, spill, illness or other.

All incidents are to be immediately reported to the Dispatcher by telephone.

The Master’s Incident Report is to be forwarded to the Fleet Operations office not later than 0800 of the day following the incident.

It is the master’s responsibility to ensure that witness statements and a report of alleged injured persons are obtained and submitted.

VESSEL DATE of INCIDENT MASTER (PRINT)

QUAL. EXCEP. LOG # (OFFICE) TIME of INCIDENT MASTER (SIGNATURE)

TYPE OF INCIDENT (CHECK ONE)

INJURY COLLISION GROUNDING SPILL ILLNESS OTHER

PERSONAL INJURY/ILLNESS: Complete this section ONLY if an alleged personal injury or illness is reported. NAME POSITION SOCIAL SECURITY NUMBER

DATE OF BIRTH ADDRESS TELEPHONE

DESCRIBE THE INDIVIDUAL’S ACTIONS LEADING UP TO THE INCIDENT

WAS PPE BEING WORN AT TIME OF INCIDENT: YES / NO WHAT TYPE OF PPE: IF NO, EXPLAIN REASON WHY PPE WAS NOT BEING WORN:

INJURED EMPLOYEE’S EXPERIENCE WITH THE COMPANY: NUMBER OF YEARS: MONTHS:

Page 1 of 2 E.N. Bisso & Son, Inc. Master’s Incident Form Number: 03-15 Responsible Carrier Report Program Form Revision Date: 09/15/07 MASTER’S DESCRIPTION OF THE INCIDENT (ATTACH ADDITIONAL PAGES AND/OR DRAWINGS IF NEEDED)

ADDITIONAL PAGES: YES / NO DRAWINGS: YES / NO PHOTOGRAPHS TAKEN: YES / NO

GEOGRAPHIC LOCATION OF INCIDENT:

WEATHER CONDITIONS AT TIME OF INCIDENT

Overcast/Clear: Visibility: Precipitation: Temperature: Wind: Seas: Swell: Other:

WITNESSES TO THE INCIDENT NAME POSITION ADDRESS TELEPHONE

NAMES OF OTHER VESSELS IN THE AREA

In the 24 hours immediately prior to the reported incident, how many hours did each of the persons listed below work? MASTER: RELIEF MASTER: ENGINEER: OILER: DECKHAND: DECKHAND:

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