5 Details of navigational systems and equipment
| Item | Actual provision |
|---|
| 1.1 Standard magnetic compass | .......................................................………….......... |
| 1.2 Spare magnetic compass | ...............................................................………….. |
| 1.3 Gyro compass | ...............................................................………….. |
| 1.4 Gyro compass heading repeater | ...............................................................………….. |
| 1.5 Gyro compass bearing repeater | ...............................................................………….. |
| 1.6 Heading or track control system | ...............................................................………….. |
| 1.7 Pelorus or compass bearing device | ...............................................................………….. |
| 1.8 Means of correcting headings and bearings | ...............................................................………….. |
| 1.9 Transmitting heading device (THD) | ...............................................................………….. |
| 2.1 Nautical charts/Electronic chart display and information system (ECDIS)† | ...............................................................………….. |
| 2.2 Back up arrangements for ECDIS | ...............................................................………….. |
| 2.3 Nautical publications | ...............................................................………….. |
| 2.4 Back up arrangements for electronic nautical publications | ...............................................................………….. |
| 3.1 Receiver for a global navigation satellite system/terrestrial radionavigation system † | ...............................................................………….. |
| 3.2 9 GHz radar | ...............................................................………….. |
| 3.3 Second radar (3 GHz/9 GHz†) | ...............................................................………….. |
| 3.4 Automatic radar plotting aid (ARPA) |
<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr><td style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span style="font-family:'CG Times', serif; font-weight:bold">To: ..................................................</span></p><p style="text-align:center; font-size:10pt"><span style="font-family:'CG Times', serif; font-style:italic">(Prescribed person)</span></p></td><td style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span style="font-family:'CG Times', serif; font-weight:bold"></span></p></td></tr><tr><td style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt"><span style="font-family:'CG Times', serif; font-style:italic">Name of ship:</span></p></td><td style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt"><span style="font-family:'CG Times', serif; font-style:italic">Home port or port of registry:</span></p></td></tr><tr><td style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt"><span style="font-family:'CG Times', serif; font-style:italic">IMO Number:</span></p></td><td style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt"><span style="font-family:'CG Times', serif; font-style:italic">Gross tonnage</span><span style="font-family:'CG Times', serif; font-weight:bold">:</span></p></td></tr><tr><td style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt"><span style="font-family:'CG Times', serif; font-style:italic"></span></p></td><td style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt"><span style="font-family:'CG Times', serif; font-weight:bold"></span></p></td></tr><tr><td style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:12pt"><span style="font-family:'CG Times', serif; font-style:italic">Name & address of owner or operator:</span></p></td><td style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:12pt"><span style="font-family:'CG Times', serif; font-weight:bold"></span></p></td></tr><tr><td style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:12pt"><span style="font-family:'CG Times', serif; font-style:italic">Name & address of Master:</span></p></td><td style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:12pt"><span style="font-family:'CG Times', serif; font-weight:bold"></span></p></td></tr><tr><td style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt"><span style="font-family:'CG Times', serif; font-style:italic">Name of Classification Society:</span></p></td><td style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt"><span style="font-family:'CG Times', serif; font-weight:bold"></span></p></td></tr><tr><td colspan="2" style="width:485.3pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="text-align:center"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr><td colspan="2" style="width:485.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="text-align:center"><span style="font-family:'CG Times', serif">NATURE OF PARTICULARS OF ALTERATION OR REPLACEMENT</span></p></td></tr><tr><td style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:156pt"><span style="font-family:'CG Times', serif; font-weight:bold"></span></p></td><td style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:156pt; text-align:right"><span style="font-family:'CG Times', serif; font-weight:bold"></span></p></td></tr><tr><td style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span style="font-family:'CG Times', serif; font-weight:bold">..................................................</span></p><p style="font-size:10pt"><span style="font-family:'CG Times', serif; font-style:italic">Signature of owner, master or agent</span></p></td><td style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="text-align:right"><span style="font-family:'CG Times', serif; font-weight:bold">...........................</span></p><p style="text-align:right; font-size:10pt"><span style="font-family:'CG Times', serif; font-style:italic">Date</span></p></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr><td colspan="7" style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span style="font-weight:bold">SHIP DETAILS</span></p></td><td colspan="10" style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span style="font-weight:bold"></span></p></td></tr><tr><td colspan="7" style="width:237.25pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:18pt"><span>Ship's name</span></p></td><td colspan="10" style="width:237.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:18pt"><span></span></p></td></tr><tr><td colspan="7" style="width:237.25pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>IMO number</span></p></td><td colspan="10" style="width:237.25pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Flag</span></p></td></tr><tr><td colspan="7" style="width:237.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Call sign</span></p></td><td colspan="10" style="width:237.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Satcom number</span></p></td></tr><tr><td colspan="7" style="width:237.25pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Master</span></p></td><td colspan="10" style="width:237.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span></span></p></td></tr><tr><td colspan="7" style="width:237.25pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Gross tonnage</span></p></td><td colspan="10" style="width:237.25pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>No. of persons on board</span></p></td></tr><tr><td colspan="7" style="width:237.25pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Class society</span></p></td><td colspan="10" style="width:237.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span></span></p></td></tr><tr><td colspan="7" style="width:237.25pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Propulsion</span></p></td><td colspan="10" style="width:237.25pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>IOPP certificate date of issue</span></p></td></tr><tr><td colspan="3" style="width:82.75pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span>Ship type</span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span></span></p></td><td style="width:51.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span></span></p></td><td colspan="2" style="width:57.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span></span></p></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span></span></p></td><td colspan="3" style="width:51.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span></span></p></td><td style="width:51.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span></span></p></td><td style="width:51.55pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:51.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Container</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:51.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Tanker</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="3" style="width:68.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Bulk Carrier</span></p></td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:40.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Tug</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:51.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>OSV</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:51.55pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Other</span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:51.55pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:51.55pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="2" style="width:57.25pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="2" style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="3" style="width:51.55pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:51.55pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:51.55pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td></tr><tr><td colspan="7" style="width:237.25pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:48pt"><span>Operator's name and address</span></p></td><td colspan="10" style="width:237.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:48pt"><span></span></p></td></tr><tr><td colspan="7" style="width:237.25pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:18pt"><span>Responsible Officer (ISM designated person)</span></p></td><td colspan="10" style="width:237.25pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:18pt"><span>Contact number</span></p></td></tr><tr><td colspan="7" style="width:237.25pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:30pt"><span>Agents and P&I Club</span></p></td><td colspan="10" style="width:237.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:30pt"><span></span></p></td></tr><tr><td colspan="7" style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt"><span style="font-weight:bold">INCIDENT DETAILS</span></p></td><td colspan="10" style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt"><span style="font-weight:bold"></span></p></td></tr><tr><td colspan="7" style="width:237.25pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Voyage</span></p><p class="FootnoteText" style="margin-top:12pt; margin-bottom:12pt"><span>From</span></p></td><td colspan="10" style="width:237.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span></span></p><p class="FootnoteText" style="margin-top:12pt; margin-bottom:12pt"><span>To</span></p></td></tr><tr><td colspan="7" style="width:237.25pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Ship's location</span><br><span>(eg port, at sea, lat, long)</span></p></td><td colspan="10" style="width:237.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span></span></p></td></tr><tr><td colspan="7" style="width:237.25pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Location on ship where</span><br><span>incident occurred</span></p></td><td colspan="10" style="width:237.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span></span></p></td></tr><tr><td colspan="12" style="width:322.3pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Date & time</span><br><span>of incident</span><span style="width:28.96pt; display:inline-block"> </span><span style="width:36pt; display:inline-block"></span><span style="width:36pt; display:inline-block"></span><span>/</span><span style="width:33.22pt; display:inline-block"> </span><span style="width:36pt; display:inline-block"></span><span>/</span><span style="width:33.22pt; display:inline-block"> </span><span style="width:36pt; display:inline-block"></span><span>am/pm</span></p></td><td colspan="5" style="width:152.2pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>No. of persons</span><br><span>involved</span></p></td></tr><tr style="height:0pt"><td style="width:14.2pt"></td><td style="width:17pt"></td><td style="width:62.35pt"></td><td style="width:17pt"></td><td style="width:62.35pt"></td><td style="width:17pt"></td><td style="width:58.15pt"></td><td style="width:9.9pt"></td><td style="width:11.35pt"></td><td style="width:5.65pt"></td><td style="width:11.35pt"></td><td style="width:46.8pt"></td><td style="width:4.25pt"></td><td style="width:17pt"></td><td style="width:62.35pt"></td><td style="width:17pt"></td><td style="width:62.4pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr><td colspan="3" style="width:244.35pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span style="font-weight:bold">Nature of incident</span></p></td><td style="width:6.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:213.15pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Collision</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>MARPOL Ship Defects</span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="2" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Grounding</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Serious Personal Injury</span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="2" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Fire</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Death</span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="2" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Structural Failure</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Disappearance</span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="2" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Flooding</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Loss</span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="2" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Machinery failure</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Presumed Lost</span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="2" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Cargo Gear</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Close Quarters Situation</span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="2" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Pilotage</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Births</span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="2" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Dangerous Goods</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Other (specify)</span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="2" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td></tr><tr><td colspan="6" style="width:485.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span style="font-weight:bold">DESCRIPTION OF INCIDENT/DAMAGE</span><br><span style="font-weight:bold">Note: If incident occurred under pilotage, include name of pilot</span></p></td></tr><tr><td style="width:3.4pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; 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padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td colspan="3" style="width:244.35pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt; margin-bottom:6pt"><span style="font-weight:bold">OTHER RELEVANT INFORMATION</span></p></td><td colspan="2" style="width:204.65pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt; margin-bottom:6pt"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt; margin-bottom:6pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:230.15pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:204.65pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:14.7pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr style="height:0pt"><td style="width:14.2pt"></td><td style="width:17pt"></td><td style="width:223.95pt"></td><td style="width:17pt"></td><td style="width:198.45pt"></td><td style="width:25.5pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr><td colspan="7" style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span style="font-weight:bold">SHIP DETAILS</span></p></td><td style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span style="font-weight:bold"></span></p></td></tr><tr><td colspan="7" style="width:237.25pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:18pt"><span>Ship's name</span></p></td><td style="width:237.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:18pt"><span></span></p></td></tr><tr><td colspan="7" style="width:237.25pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>IMO number</span></p></td><td style="width:237.25pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Flag</span></p></td></tr><tr><td colspan="7" style="width:237.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Call sign</span></p></td><td style="width:237.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Satcom number</span></p></td></tr><tr><td colspan="7" style="width:237.25pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Master</span></p></td><td style="width:237.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span></span></p></td></tr><tr><td colspan="7" style="width:237.25pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Gross tonnage</span></p></td><td style="width:237.25pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Propulsion</span></p></td></tr><tr><td colspan="7" style="width:237.25pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Class society</span></p></td><td style="width:237.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span></span></p></td></tr><tr><td colspan="7" style="width:237.25pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:48pt"><span>Operator's name and address</span></p></td><td style="width:237.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td colspan="7" style="width:237.25pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:30pt"><span>Agents and P&I Club</span></p></td><td style="width:237.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td colspan="5" style="width:180.55pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:18pt"><span>Date & time of incident</span></p></td><td colspan="3" style="width:293.95pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Ship's location (eg port, at sea, lat, long)</span></p></td></tr><tr><td colspan="8" style="width:485.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt; margin-bottom:6pt"><span style="font-weight:bold">Part 1 - To be completed if reporting under Marine Orders Part 32</span></p></td></tr><tr><td colspan="5" style="width:180.55pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:18pt"><span>Person-in-charge</span></p></td><td colspan="3" style="width:293.95pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span></span></p></td></tr><tr><td colspan="5" style="width:180.55pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:24pt"><span>Employer of person-in-charge</span></p></td><td colspan="3" style="width:293.95pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:24pt"><span></span></p></td></tr><tr><td colspan="5" style="width:180.55pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt; margin-bottom:3pt"><span>Incident</span></p></td><td colspan="3" style="width:293.95pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt; margin-bottom:3pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:79.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Injury</span></p></td><td style="width:21.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>►</span></p></td><td colspan="4" style="width:331.1pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>If injury, complete parts 4 - 8</span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:79.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:21.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="4" style="width:331.1pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:79.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Gear failure</span></p></td><td style="width:21.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>►</span></p></td><td colspan="4" style="width:331.1pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>If gear failure, complete parts 5 - 8</span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:79.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:21.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="4" style="width:331.1pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:79.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Dangerous Goods</span></p></td><td style="width:21.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>►</span></p></td><td colspan="4" style="width:331.1pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>If dangerous goods, complete parts 5 - 8</span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:79.9pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="3" style="width:78.25pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="2" style="width:274.4pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td></tr><tr style="height:0pt"><td style="width:14.2pt"></td><td style="width:17pt"></td><td style="width:90.7pt"></td><td style="width:32.3pt"></td><td style="width:37.15pt"></td><td style="width:19.6pt"></td><td style="width:37.1pt"></td><td style="width:248.1pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr><td colspan="14" style="width:485.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt; margin-bottom:6pt"><span style="font-weight:bold">Part 2 - To be completed if reporting under sections 268, 269 or 417 of the </span><span style="font-weight:bold; font-style:italic">Navigation Act 1912</span><span style="font-weight:bold"> (other than births) or section 19 of the </span><span style="font-weight:bold; font-style:italic">Transport Safety Investigation Act 2003</span></p></td></tr><tr><td colspan="8" style="width:237.25pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Voyage</span></p><p class="FootnoteText" style="margin-top:12pt; margin-bottom:12pt"><span>From</span></p></td><td colspan="6" style="width:237.25pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span></span></p><p class="FootnoteText" style="margin-top:12pt; margin-bottom:12pt"><span>To</span></p></td></tr><tr><td colspan="7" style="width:180.55pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span style="font-weight:bold">Incident description</span></p></td><td colspan="7" style="width:293.95pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="3" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Grounding</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Foundering</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Stranding</span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="3" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="2" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="3" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Collision</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Capsize</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Flooding</span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:7pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:7pt"><span></span></p></td><td colspan="3" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:7pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:7pt"><span></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:7pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:7pt"><span></span></p></td><td colspan="2" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:7pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="3" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Fire</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Explosion</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Machinery failure</span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="3" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="2" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="3" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Structural failure</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Close Quarters</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Disappearance</span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="3" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="2" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="3" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Loss</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Presumed lost</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Injury</span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="3" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="2" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="3" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Death</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="5" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Dangerous occurrence</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:133.8pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span>Illness</span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="3" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="2" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="3" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span>Other (specify)</span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td><td colspan="2" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="3" style="width:130.95pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="5" style="width:133.8pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td><td colspan="2" style="width:133.8pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:6pt"><span></span></p></td></tr><tr><td colspan="7" style="width:180.55pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span style="font-weight:bold">Place of incident</span></p></td><td colspan="7" style="width:293.95pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span>Machinery spaces</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span>Accommodation block</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span></span></p></td><td colspan="2" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span>Galley</span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt; font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt; font-size:6pt"><span></span></p></td><td colspan="3" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt; font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt; font-size:6pt"><span></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt; font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt; font-size:6pt"><span></span></p></td><td colspan="2" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt; font-size:6pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span>Deck/cargo spaces</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span>Gangway/pilot ladder</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span></span></p></td><td colspan="2" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span>Wharf</span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt; font-size:7pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt; font-size:7pt"><span></span></p></td><td colspan="3" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt; font-size:7pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt; font-size:7pt"><span></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt; font-size:7pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt; font-size:7pt"><span></span></p></td><td colspan="2" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt; font-size:7pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span></span></p></td><td colspan="3" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span>Other (specify)</span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span></span></p></td><td colspan="2" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span></span></p></td></tr><tr><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt; font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt; font-size:6pt"><span></span></p></td><td colspan="3" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt; font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt; font-size:6pt"><span></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt; font-size:6pt"><span></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt; font-size:6pt"><span></span></p></td><td colspan="2" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt; font-size:6pt"><span></span></p></td></tr><tr><td colspan="4" style="width:153.65pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:24pt"><span>Crew numbers</span></p></td><td colspan="6" style="width:156.45pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:24pt"><span>Passenger numbers</span></p></td><td colspan="4" style="width:153.65pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:24pt"><span>Cargo</span></p></td></tr><tr><td colspan="14" style="width:485.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt; margin-bottom:6pt"><span style="font-weight:bold">Part 3 - To be completed if reporting under section 417 of the </span><span style="font-weight:bold; font-style:italic">Navigation Act 1912</span><span style="font-weight:bold"> (Births)</span></p></td></tr><tr><td colspan="13" style="width:350.65pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span>Child's name</span></p></td><td style="width:123.85pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span>Gender</span><br><span>M/F</span></p></td></tr><tr><td colspan="3" style="width:123.85pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Date of birth</span></p></td><td colspan="11" style="width:350.65pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span>Place</span></p></td></tr><tr><td colspan="3" style="width:123.85pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Mother's full name</span></p></td><td colspan="11" style="width:350.65pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span></span></p></td></tr><tr><td colspan="9" style="width:293.95pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Town & country of birth</span></p></td><td colspan="5" style="width:180.55pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span>Australian resident</span><br><span>Yes/No</span></p></td></tr><tr><td colspan="9" style="width:293.95pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Father's full name</span></p></td><td colspan="5" style="width:180.55pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span></span></p></td></tr><tr><td colspan="9" style="width:293.95pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span>Town & country of birth</span></p></td><td colspan="5" style="width:180.55pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span>Australian resident</span><br><span>Yes/No</span></p></td></tr><tr style="height:0pt"><td style="width:14.2pt"></td><td style="width:17pt"></td><td style="width:103.45pt"></td><td style="width:29.8pt"></td><td style="width:8.5pt"></td><td style="width:17pt"></td><td style="width:1.4pt"></td><td style="width:56.7pt"></td><td style="width:56.7pt"></td><td style="width:26.95pt"></td><td style="width:2.85pt"></td><td style="width:17pt"></td><td style="width:9.9pt"></td><td style="width:134.7pt"></td></tr></tbody></table>
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<table cellspacing="0" cellpadding="0" style="width:496.15pt; border-collapse:collapse"><tbody><tr><td colspan="17" style="width:485.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt; font-size:12pt"><span style="font-family:'CG Times (W1)', serif; font-size:10pt; font-weight:bold; letter-spacing:-0.3pt">Part 4 - To be completed if reporting under section 107 of the </span><span style="font-family:'CG Times (W1)', serif; font-size:10pt; font-weight:bold; font-style:italic; letter-spacing:-0.3pt">Occupational Health & Safety (Maritime Industry) Act 1993</span></p></td></tr><tr><td colspan="17" style="width:485.35pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:3pt"><span style="font-family:'CG Times', serif">Name of affected person</span></p></td></tr><tr><td colspan="9" style="width:182.85pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span style="font-family:'CG Times', serif">Date of birth</span></p></td><td colspan="3" style="width:126.25pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span style="font-family:'CG Times', serif">Gender</span><br><span style="font-family:'CG Times', serif">M/F</span></p></td><td colspan="5" style="width:154.65pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText"><span style="font-family:'CG Times', serif">PIN</span></p></td></tr><tr><td colspan="17" style="width:485.35pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:12pt"><span style="font-family:'CG Times', serif">Home address</span></p></td></tr><tr><td colspan="4" style="width:123.85pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span style="font-family:'CG Times', serif">Australian resident</span><br><span style="font-family:'CG Times', serif">Yes / No</span></p></td><td colspan="13" style="width:350.7pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:6pt"><span style="font-family:'CG Times', serif">Town & country of birth</span></p></td></tr><tr style="height:3pt"><td colspan="3" style="width:122.45pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif">Capacity</span></p></td><td colspan="2" style="width:6.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:94.1pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="4" style="width:91.25pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:94.15pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:3pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif">Crew</span></p></td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:94.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif">Contractor</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="4" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif">Waterside worker</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:94.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif">Supplier</span></p></td></tr><tr style="height:3pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; font-size:6pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; font-size:6pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; font-size:6pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; font-size:6pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:94.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; font-size:6pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; font-size:6pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="4" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; font-size:6pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; font-size:6pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:94.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; font-size:6pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:3pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif">Watchkeeper</span></p></td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="12" style="width:335.1pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif">Other (specify) ……………………………………………………………………………..</span></p></td></tr><tr style="height:3pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; font-size:6pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; font-size:6pt"><span style="font-family:Symbol, serif; font-weight:bold"></span></p></td><td style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; font-size:6pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; font-size:6pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:94.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; font-size:6pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; font-size:6pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="4" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; font-size:6pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; font-size:6pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:94.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; font-size:6pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:3pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; font-size:9pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="16" style="width:471.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; font-size:9pt"><span style="font-family:'CG Times', serif">show watch period:</span><span style="font-family:'CG Times', serif"> </span><span style="font-family:'CG Times', serif">from ……………..to ………………..</span><span style="font-family:'CG Times', serif"> </span><span style="font-family:'CG Times', serif">Time since last rest period ……………………….…</span></p></td></tr><tr style="height:3pt"><td colspan="4" style="width:123.85pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif">Logbook</span><br><span style="font-family:'CG Times', serif">entry date</span></p></td><td colspan="13" style="width:350.7pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif">Rank</span></p></td></tr><tr style="height:3pt"><td colspan="6" style="width:154.55pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif">Hours of duty</span><br><span style="width:28.35pt; font-family:'CG Times', serif; display:inline-block"></span><span style="font-family:'CG Times', serif">Time on:</span></p></td><td colspan="6" style="width:154.55pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><br><span style="font-family:'CG Times', serif">Time off:</span></p></td><td colspan="5" style="width:154.65pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif">Hours before duty</span></p></td></tr><tr style="height:1.4pt"><td colspan="3" style="width:122.45pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Affected area</span></p></td><td colspan="2" style="width:6.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:94.1pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="4" style="width:91.25pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:94.15pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:1.25pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Head (1)</span></p></td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:94.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Eyes (1)</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="4" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Trunk (3)</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:94.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Arms (4)</span></p></td></tr><tr style="height:1.25pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:94.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="4" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:94.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:1.25pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Hands (4)</span></p></td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:94.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Legs (5)</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="4" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Internal (7)</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:94.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Back (3)</span></p></td></tr><tr style="height:1.25pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:94.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="4" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:94.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:1.25pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Neck (2)</span></p></td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:94.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Fingers (4)</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="4" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Feet (5)</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:94.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Toes (5)</span></p></td></tr><tr style="height:1.25pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:94.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="4" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:94.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:1.25pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="15" style="width:454.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Other (specify)</span></p></td></tr><tr style="height:1.25pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:91.25pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="2" style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:94.1pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="4" style="width:91.25pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:94.15pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:1.4pt"><td colspan="7" style="width:165pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Type of injury</span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="3" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Drowning (150)</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Crushing (100)</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="3" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Laceration (060/080)</span></p></td></tr><tr style="height:1pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="3" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Burns & scalds (120)</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Hernia (450)</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="3" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Fracture (020/010)</span></p></td></tr><tr style="height:1pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="3" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Electric shock (150)</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Amputation (070)</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="3" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Foreign Body (110/090)</span></p></td></tr><tr style="height:1pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="3" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Abrasion (090)</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Bruising (100)</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="3" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Asphyxia (110/150/140)</span></p></td></tr><tr style="height:1pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="3" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Strain & sprain (040)</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="9" style="width:292.55pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Other (specify)</span></p></td></tr><tr style="height:1pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:133.8pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:130.95pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="3" style="width:133.8pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:1.4pt"><td colspan="7" style="width:165pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Result of incident</span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="3" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Death</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Serious injury</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="3" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Minor injury</span></p></td></tr><tr style="height:1pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="3" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Near miss</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Temporary disability</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="3" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Partial disability</span></p></td></tr><tr style="height:1pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="3" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Permanent disability</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Disappearance</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="3" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Time off work</span></p></td></tr><tr style="height:1pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="3" style="width:133.8pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:3.4pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:133.8pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">None</span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="9" style="width:292.55pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Other (specify)</span></p></td></tr><tr style="height:1pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:133.8pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:130.95pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="3" style="width:133.8pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:0pt"><td style="width:14.2pt"></td><td style="width:17pt"></td><td style="width:102.05pt"></td><td style="width:1.4pt"></td><td style="width:15.6pt"></td><td style="width:15.1pt"></td><td style="width:10.45pt"></td><td style="width:17pt"></td><td style="width:0.85pt"></td><td style="width:61.5pt"></td><td style="width:17pt"></td><td style="width:58.55pt"></td><td style="width:3.85pt"></td><td style="width:17pt"></td><td style="width:22.65pt"></td><td style="width:17pt"></td><td style="width:104.95pt"></td></tr></tbody></table>
```
<table cellspacing="0" cellpadding="0" style="width:496.9pt; border-collapse:collapse"><tbody><tr style="height:3pt"><td colspan="7" style="width:485.35pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Incident factors</span></p></td></tr><tr style="height:3pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="2" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Machinery and (mainly) fixed plant (1)</span></p></td><td style="width:6.2pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="2" style="width:213.2pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Materials and substances (6)</span></p></td></tr><tr style="height:3pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:454.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:3pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="2" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Mobile plant and transport (2)</span></p></td><td style="width:6.2pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="2" style="width:213.2pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Environmental agencies (7)</span></p></td></tr><tr style="height:3pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:454.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:3pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="2" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Powered equipment, tools and appliances (3)</span></p></td><td style="width:6.2pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="2" style="width:213.2pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Animal, human and biological agencies (8)</span></p></td></tr><tr style="height:3pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:454.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:3pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:454.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Non-powered hand tools, appliances and other equipment (4)</span></p></td></tr><tr style="height:3pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:454.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:3pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="2" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Chemicals and chemical products (5)</span></p></td><td style="width:6.2pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="2" style="width:213.2pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif">Other and unspecified agencies (9)</span></p></td></tr><tr style="height:3pt"><td style="width:3.4pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td><td colspan="5" style="width:454.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="font-size:11pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr style="height:3pt"><td colspan="7" style="width:485.35pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; margin-bottom:24pt"><span style="font-family:'CG Times', serif">Cause of injury/illness</span></p></td></tr><tr style="height:3pt"><td colspan="3" style="width:237.25pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif">Date left ship</span></p></td><td colspan="4" style="width:237.3pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif">Expected period</span><br><span style="font-family:'CG Times', serif">of incapacity</span></p></td></tr><tr style="height:3pt"><td colspan="3" style="width:237.25pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; margin-bottom:48pt"><span style="font-family:'CG Times', serif">Treatment given on board ship</span></p></td><td colspan="4" style="width:237.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; margin-bottom:48pt"><span style="font-family:'CG Times', serif"></span></p></td></tr><tr><td colspan="7" style="width:485.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif; font-weight:bold">Part 5 – Explanation and Description</span><br><span style="font-family:'CG Times', serif; font-weight:bold">State Cause and give names and addresses of any witnesses</span></p></td></tr><tr><td colspan="7" style="width:485.35pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:48pt"><span style="font-family:'CG Times', serif; font-weight:bold"></span></p></td></tr><tr><td colspan="7" style="width:485.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif; font-weight:bold">Part 6 - Incident narrative</span></p></td></tr><tr><td colspan="7" style="width:485.35pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:48pt"><span style="font-family:'CG Times', serif; font-weight:bold"></span></p></td></tr><tr><td colspan="7" style="width:485.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif; font-weight:bold">Part 7 - Action taken to prevent similar occurrences</span></p></td></tr><tr><td colspan="7" style="width:485.35pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-bottom:48pt"><span style="font-family:'CG Times', serif; font-weight:bold"></span></p></td></tr><tr><td colspan="7" style="width:485.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt"><span style="font-family:'CG Times', serif; font-weight:bold">Part 8 - Details of person completing report</span></p></td></tr><tr><td colspan="7" style="width:485.35pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt"><span style="font-family:'CG Times', serif">Name</span></p></td></tr><tr><td colspan="3" style="width:237.25pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt"><span style="font-family:'CG Times', serif">Position</span></p></td><td colspan="4" style="width:237.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt"><span style="font-family:'CG Times', serif">Contact number</span></p></td></tr><tr><td colspan="6" style="width:379pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt"><span style="font-family:'CG Times', serif">Signature</span></p></td><td style="width:95.55pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt"><span style="font-family:'CG Times', serif">Date</span><span style="width:9.47pt; font-family:'CG Times', serif; display:inline-block"> </span><span style="font-family:'CG Times', serif">/</span><span style="width:17.07pt; font-family:'CG Times', serif; display:inline-block"> </span><span style="font-family:'CG Times', serif">/</span></p></td></tr><tr style="height:0pt"><td style="width:14.2pt"></td><td style="width:17pt"></td><td style="width:216.85pt"></td><td style="width:7.1pt"></td><td style="width:17pt"></td><td style="width:117.65pt"></td><td style="width:106.35pt"></td></tr></tbody></table>
```