<p> E.N. Bisso & Son, Inc. Master’s Incident Form Number: 03-15 Responsible Carrier Report Program Form Revision Date: 09/15/07</p><p>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.</p><p>All incidents are to be immediately reported to the Dispatcher by telephone.</p><p>The Master’s Incident Report is to be forwarded to the Fleet Operations office not later than 0800 of the day following the incident.</p><p>It is the master’s responsibility to ensure that witness statements and a report of alleged injured persons are obtained and submitted.</p><p>VESSEL DATE of INCIDENT MASTER (PRINT)</p><p>QUAL. EXCEP. LOG # (OFFICE) TIME of INCIDENT MASTER (SIGNATURE)</p><p>TYPE OF INCIDENT (CHECK ONE)</p><p>INJURY COLLISION GROUNDING SPILL ILLNESS OTHER</p><p>PERSONAL INJURY/ILLNESS: Complete this section ONLY if an alleged personal injury or illness is reported. NAME POSITION SOCIAL SECURITY NUMBER</p><p>DATE OF BIRTH ADDRESS TELEPHONE</p><p>DESCRIBE THE INDIVIDUAL’S ACTIONS LEADING UP TO THE INCIDENT</p><p>WAS PPE BEING WORN AT TIME OF INCIDENT: YES / NO WHAT TYPE OF PPE: IF NO, EXPLAIN REASON WHY PPE WAS NOT BEING WORN:</p><p>INJURED EMPLOYEE’S EXPERIENCE WITH THE COMPANY: NUMBER OF YEARS: MONTHS: </p><p>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)</p><p>ADDITIONAL PAGES: YES / NO DRAWINGS: YES / NO PHOTOGRAPHS TAKEN: YES / NO</p><p>GEOGRAPHIC LOCATION OF INCIDENT: </p><p>WEATHER CONDITIONS AT TIME OF INCIDENT</p><p>Overcast/Clear: Visibility: Precipitation: Temperature: Wind: Seas: Swell: Other: </p><p>WITNESSES TO THE INCIDENT NAME POSITION ADDRESS TELEPHONE</p><p>NAMES OF OTHER VESSELS IN THE AREA</p><p>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: </p><p>Page 2 of 2</p>