Get a plain-English read of Appendix 23

Turn the raw legal text into a practical explanation grounded in Marine Orders - Part 32: Cargo Handling Equipment, Issue 2 (Order No. 14 of 1997).

Appendix 23

Forms

Form MO 32/1

CERTIFICATE OF TEST AND EXAMINATION OF DERRICKS, CRANES AND CARGO LIFTS

Ship		Certificate No

	Articles		Angle to the
Situation	Distinguishing numbers or marks	Description	horizontal of derrick or crane for purpose of test*	Proof load applied	Date of test	Safe working load	Method used in applying the proof load

Name and address of testing establishment..............................................................................................................................................................................................................................................................................................................................................................

CERTIFICATION

<table cellspacing="0" cellpadding="0" style="margin-top:0pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:484.75pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:6pt"><span style="font-family:'Times New Roman', serif; font-size:10pt">I,</span><span style="font-family:'Times New Roman', serif; font-size:10pt"> </span><span style="font-family:'Times New Roman', serif; font-size:10pt">....................................................................,a responsible person for the purposes of Marine Orders, Part 32 (Cargo Handling Equipment), hereby certify that on the date shown in the column headed 'Date of test' in the table above:</span></p><p style="margin-top:6pt; margin-left:25.2pt; margin-bottom:6pt; text-indent:-25.2pt"><span style="font-family:Symbol, serif; font-size:10pt"></span><span style="width:20.6pt; text-indent:0pt; display:inline-block"> </span><span style="font-family:'Times New Roman', serif; font-size:10pt">I tested the articles of materials handling equipment identified in that table, in the manner specified in Appendix 5 to Marine Orders, Part 32 for the above mentioned testing establishment and am in all respects satisfied that each article identified is of sufficient strength to carry the safe working load specified in the column headed 'Safe working load' in the table, relating to that article; and</span></p><p style="margin-top:6pt; margin-left:25.2pt; text-indent:-25.2pt"><span style="font-family:Symbol, serif; font-size:10pt"></span><span style="width:20.6pt; text-indent:0pt; display:inline-block"> </span><span style="font-family:'Times New Roman', serif; font-size:10pt">I made a thorough examination of each article identified and am in all respects satisfied from the examination that each such article withstood the proof test without injury or deformation.</span></p></td></tr><tr><td style="width:236.95pt; 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 style="margin-top:6pt; margin-bottom:24pt"><span style="font-family:'Times New Roman', serif; font-size:10pt">Position</span></p></td><td style="width:236.95pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:24pt"><span style="font-family:'Times New Roman', serif; font-size:10pt">Technical qualifications</span></p></td></tr><tr><td style="width:236.95pt; 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 style="margin-top:6pt"><span style="font-family:'Times New Roman', serif; font-size:10pt">Address .......................................................................</span><br><span style="font-family:'Times New Roman', serif; font-size:10pt">.....................................................................................</span></p></td><td style="width:236.95pt; 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 style="margin-top:6pt; margin-bottom:6pt"><span style="font-family:'Times New Roman', serif; font-size:10pt">Signature</span></p><p style="margin-top:6pt; text-align:right"><span style="font-family:'Times New Roman', serif; font-size:10pt">....../....../......</span></p><p style="margin-top:0pt; text-align:right"><span style="font-family:'Times New Roman', serif; font-size:10pt">Date</span></p></td></tr></tbody></table>

<table cellspacing="0" cellpadding="0" style="margin-top:0pt; border:0.75pt solid #000000; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:484.75pt; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">I, ....................................................................,a responsible person for the purposes of Marine Orders, Part 32 (Cargo Handling Equipment), hereby certify that on the date shown in the column headed 'Date of test' in the table above: I tested the articles identified in that table, in the manner specified in Appendix 5 to Marine Orders, Part 32, for the above mentioned testing establishment; I am in all respects satisfied that each article identified is of sufficient strength to carry the safe working load specified in the column headed 'Safe working load' in the table, relating to that article; and I made a thorough examination of each article identified; following application of the proof load, each such article was found to have withstood the load without injury or deformation and to be free from cracks, flaws and other defects.</td></tr><tr><td style="width:236.95pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Position</td><td style="width:236.95pt; border-top:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Technical qualifications</td></tr><tr><td style="width:236.95pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Address ....................................................................... .....................................................................................</td><td style="width:236.95pt; border-top:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Signature....../....../......Date</td></tr></tbody></table>

<table cellspacing="0" cellpadding="0" style="margin-top:0pt; border:0.75pt solid #000000; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:484.75pt; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">I, ....................................................................,a responsible person for the purposes of Marine Orders, Part 32 (Cargo Handling Equipment), hereby certify that on the date shown in the column headed 'Date of test' in the table above: I tested the articles identified in that table, in the manner specified in Appendix 5 to Marine Orders, Part 32, for the above mentioned testing establishment; I made a thorough examination of each article identified; following application of the proof load, each such article was found to have withstood the load without injury or deformation and to be free from cracks, flaws and other defects.</td></tr><tr><td style="width:236.95pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Position</td><td style="width:236.95pt; border-top:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Technical qualifications</td></tr><tr><td style="width:236.95pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Address ...................................................................... .....................................................................................</td><td style="width:236.95pt; border-top:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Signature....../....../......Date</td></tr></tbody></table>

Name
Address

<table cellspacing="0" cellpadding="0" style="margin-top:0pt; border-collapse:collapse"><tbody><tr><td style="width:154.35pt; border-top:1.5pt 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">Diameter of rope (mm)</td><td colspan="2" style="width:154.35pt; border-top:1.5pt solid #000000; 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">Number of strands</td><td colspan="2" style="width:154.35pt; border-top:1.5pt 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">Number of wires per strand</td></tr><tr><td colspan="2" style="width:236.95pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Lay</td><td colspan="3" style="width:236.95pt; 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">Core</td></tr><tr><td colspan="5" style="width:484.75pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Specification to which wires conform</td></tr><tr><td colspan="4" style="width:322.05pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Breaking tensile load of sample of the rope</td><td style="width:151.95pt; 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">Date of tensile test</td></tr><tr><td colspan="5" style="width:484.75pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Safe working loadsubject to any stated qualifying conditions (such as minimum pulley diameter and direct tensile load)</td></tr><tr style="height:0pt"><td style="width:165.15pt"></td><td style="width:82.6pt"></td><td style="width:82.55pt"></td><td style="width:2.55pt"></td><td style="width:162.75pt"></td></tr></tbody></table>

Name
Address

<table cellspacing="0" cellpadding="0" style="margin-top:0pt; border-collapse:collapse"><tbody><tr><td colspan="2" style="width:484.75pt; border-top:1.5pt solid #000000; border-right:1.5pt solid #000000; border-left:1.5pt solid #000000; padding-right:4.65pt; padding-left:4.65pt; vertical-align:top">I, ....................................................................,a responsible person for the purposes of Marine Orders, Part 32 (Cargo Handling Equipment), hereby certify that the above particulars are correct.</td><td style="vertical-align:top"></td></tr><tr><td style="width:343.6pt; border-left:1.5pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:5.4pt; padding-left:4.65pt; vertical-align:top">Signature .........................................................................................</td><td colspan="2" style="width:130.95pt; border-right:1.5pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:4.65pt; padding-left:5.4pt; vertical-align:top">Date / /</td></tr><tr style="height:0pt"><td style="width:354.4pt"></td><td style="width:141.15pt"></td><td style="width:0.6pt"></td></tr></tbody></table>

Wire rope supplied to
To be used for

<table cellspacing="0" cellpadding="0" style="margin-top:0pt; border-collapse:collapse"><tbody><tr><td colspan="7" style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">SHIP DETAILS</td><td colspan="13" style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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">Ship's name</td><td colspan="13" 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"></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">IMO number</td><td colspan="13" style="width:237.25pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Flag</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">Call sign</td><td colspan="13" 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">Satcom number</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">Master</td><td colspan="13" 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"></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">Gross tonnage</td><td colspan="13" 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">No. of persons on board</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">Class society</td><td colspan="13" 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"></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">Propulsion</td><td colspan="13" 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">IOPP certificate date of issue</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">Ship type</td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:51.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:57.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:51.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:51.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:51.6pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:51.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Container</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:51.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Tanker</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="4" style="width:68.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Bulk Carrier</td><td colspan="3" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="2" style="width:40.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Tug</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:51.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">OSV</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="2" style="width:51.6pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Other</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"></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:51.55pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:51.55pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:57.25pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:51.6pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:51.55pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:51.6pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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">Operator's name and address</td><td colspan="13" 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"></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">Responsible Officer (ISM designated person)</td><td colspan="13" 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">Contact number</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">Agents and P&I Club</td><td colspan="13" 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"></td></tr><tr><td colspan="7" style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">INCIDENT DETAILS</td><td colspan="13" style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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">VoyageFrom</td><td colspan="13" 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">To</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">Ship's location (eg port, at sea, lat, long)</td><td colspan="13" 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"></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">Location on ship where incident occurred</td><td colspan="13" 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"></td></tr><tr><td colspan="14" 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">Date & time of incident / / am/pm</td><td colspan="6" 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">No.of persons involved</td></tr><tr><td colspan="8" 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">Nature of incident</td><td colspan="3" style="width:6.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" 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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="6" style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Collision</td><td colspan="3" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">MARPOL Ship Defects</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="6" style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="6" style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Grounding</td><td colspan="3" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Serious Personal Injury</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="6" style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="6" style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Fire</td><td colspan="3" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Fatality</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="6" style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="6" style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Structural Failure</td><td colspan="3" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Disappearance</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="6" style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="6" style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Flooding</td><td colspan="3" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Loss</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="6" style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="6" style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Machinery Breakdown</td><td colspan="3" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Presumed Lost</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="6" style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="6" style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Cargo Gear</td><td colspan="3" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Close Quarters Situation</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="6" style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="6" style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Pilotage</td><td colspan="3" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Births</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="6" style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="6" style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Dangerous Goods</td><td colspan="3" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Other (specify)</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="6" style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></td></tr><tr><td colspan="20" 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">DESCRIPTION OF INCIDENT/DAMAGE Note: If incident occurred under pilotage, include name of pilot</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"></td><td colspan="7" style="width:230.15pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:204.65pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td colspan="7" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" 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"></td><td colspan="11" 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"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" 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"></td><td colspan="11" 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"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" 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"></td><td colspan="11" 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"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" 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"></td><td colspan="11" 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"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" 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"></td><td colspan="11" 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"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" 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"></td><td colspan="11" 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"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" 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"></td><td colspan="11" 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"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" style="width:230.15pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:204.65pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></td></tr><tr><td colspan="8" style="width:244.35pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top">OTHER RELEVANT INFORMATION</td><td colspan="11" style="width:204.65pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" style="width:230.15pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:204.65pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td colspan="7" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" style="width:230.15pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:204.65pt; border-top:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:14.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="7" 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"></td><td colspan="11" 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"></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"></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:7.1pt"></td><td style="width:2.8pt"></td><td style="width:11.35pt"></td><td style="width:2.85pt"></td><td style="width:2.8pt"></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:36.9pt"></td><td style="width:25.5pt"></td></tr></tbody></table>

<table cellspacing="0" cellpadding="0" style="margin-top:0pt; border-collapse:collapse"><tbody><tr><td colspan="17" style="width:237.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">SHIP DETAILS</td><td colspan="12" style="width:237.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td></tr><tr><td colspan="17" 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">Ship's name</td><td colspan="12" style="width:237.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></td></tr><tr><td colspan="17" style="width:237.25pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">IMO number</td><td colspan="12" style="width:237.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Flag</td></tr><tr><td colspan="17" 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">Call sign</td><td colspan="12" style="width:237.3pt; 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">Satcom number</td></tr><tr><td colspan="17" 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">Master</td><td colspan="12" 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"></td></tr><tr><td colspan="17" 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">Gross tonnage</td><td colspan="12" 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">Propulsion</td></tr><tr><td colspan="17" 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">Class society</td><td colspan="12" 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"></td></tr><tr><td colspan="17" 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">Operator's name and address</td><td colspan="12" style="width:237.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></td></tr><tr><td colspan="17" 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">Agents and P&I Club</td><td colspan="12" style="width:237.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></td></tr><tr><td colspan="13" style="width:180.55pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Date & time of incident</td><td colspan="16" style="width:294pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Ship's location (eg port, at sea, lat, long)</td></tr><tr><td colspan="29" style="width:485.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Part 1 - To be completed if reporting under Marine Orders Part 32</td></tr><tr><td colspan="13" 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">Person-in-charge</td><td colspan="16" style="width:294pt; 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"></td></tr><tr><td colspan="13" 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">Employer of person-in-charge</td><td colspan="16" style="width:294pt; 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"></td></tr><tr><td colspan="13" 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">Incident</td><td colspan="16" style="width:294pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:83.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Injury</td><td colspan="4" style="width:17.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">→</td><td colspan="22" style="width:331.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">If injury, complete parts 4 - 8</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:83.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="4" style="width:17.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="22" style="width:331.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:83.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Gear failure</td><td colspan="4" style="width:17.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">→</td><td colspan="22" style="width:331.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">If gear failure, complete parts 5 - 8</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:83.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="4" style="width:17.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="22" style="width:331.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:83.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Dangerous Goods</td><td colspan="4" style="width:17.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">→</td><td colspan="22" style="width:331.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">If dangerous goods, complete parts 5 - 8</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"></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:83.9pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="13" style="width:74.25pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="13" 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"></td></tr><tr><td colspan="29" style="width:485.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Part 2 - To be completed if reporting under sections 268, 269 or 417 of the Navigation Act 1912 (other than births) or regulation 4 of the Navigation (Marine Casualty) Regulations</td></tr><tr><td colspan="17" 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">VoyageFrom</td><td colspan="12" style="width:237.3pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">To</td></tr><tr><td colspan="13" 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">Incident description</td><td colspan="16" style="width:294pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="8" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Grounding</td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="11" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Foundering</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></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">Stranding</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="8" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="8" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Collision</td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="11" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Capsize</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></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">Flooding</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="8" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="8" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Fire</td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="11" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Explosion</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></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">Machinery failure</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="8" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="8" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Structural failure</td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="11" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Close Quarters</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></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">Disappearance</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="8" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="8" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Loss</td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="11" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Presumed lost</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></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">Injury</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="8" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="8" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Death</td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="11" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Dangerous occurrence</td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="8" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="8" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Other (specify)</td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="8" style="width:130.95pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="11" style="width:133.8pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="5" 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"></td></tr><tr><td colspan="13" 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">Place of incident</td><td colspan="16" style="width:294pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="8" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Machinery spaces</td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="11" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Accommodation block</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></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">Galley</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="8" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="8" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Deck/cargo spaces</td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="11" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Gangway/pilot ladder</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></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">Wharf</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="8" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="8" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Other (specify)</td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="8" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="11" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></td></tr><tr><td colspan="8" style="width:153.65pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Crew numbers</td><td colspan="14" style="width:156.45pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Passenger numbers</td><td colspan="7" style="width:153.65pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Cargo</td></tr><tr><td colspan="29" style="width:485.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Part 3 - To be completed if reporting under section 417 of the Navigation Act 1912 (Births)</td></tr><tr><td colspan="25" 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">Child's name</td><td colspan="4" style="width:123.9pt; 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">Gender M/F</td></tr><tr><td colspan="5" style="width:123.85pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Date of birth</td><td colspan="24" style="width:350.7pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Place</td></tr><tr><td colspan="5" style="width:123.85pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top">Mother's full name</td><td colspan="24" style="width:350.7pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></td></tr><tr><td colspan="20" style="width:293.95pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Town & country of birth</td><td colspan="9" style="width:180.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Australian resident Yes/No</td></tr><tr><td colspan="20" style="width:293.95pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top">Father's full name</td><td colspan="9" style="width:180.6pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></td></tr><tr><td colspan="20" style="width:293.95pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Town & country of birth</td><td colspan="9" style="width:180.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Australian resident Yes/No</td></tr><tr><td colspan="29" style="width:485.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Part 4 - To be completed if reporting under section 107 of the Occupational Health & Safety (Maritime Industry) Act 1993</td></tr><tr><td colspan="29" 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">Name of affected person</td></tr><tr><td colspan="15" style="width:182.85pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Date of birth</td><td colspan="6" style="width:126.25pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Gender M/F</td><td colspan="8" style="width:154.65pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">PIN</td></tr><tr><td colspan="29" 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">Home address</td></tr><tr><td colspan="5" 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">Australian resident Yes / No</td><td colspan="24" 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">Town & country of birth</td></tr><tr style="height:3pt"><td colspan="4" 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">Capacity</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"></td><td colspan="12" style="width:94.1pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="7" style="width:91.25pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="2" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Crew</td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="12" style="width:94.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Contractor</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="7" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Waterside worker</td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:94.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Supplier</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="12" style="width:94.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="7" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:94.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="2" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Watchkeeper</td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="23" style="width:335.1pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Other (specify) ……………………………………………………………………………..</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="12" style="width:94.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="7" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:94.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="28" style="width:471.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">show watch period: from ……………..to ……………….. Time since last rest period ……………………….…</td></tr><tr style="height:3pt"><td colspan="5" 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">Logbook entry date</td><td colspan="24" 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">Rank</td></tr><tr style="height:3pt"><td colspan="9" 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">Hours of duty Time on:</td><td colspan="12" 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"> Time off:</td><td colspan="8" 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">Hours before duty</td></tr><tr style="height:1.4pt"><td colspan="4" 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">Affected area</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"></td><td colspan="12" style="width:94.1pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="7" style="width:91.25pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="2" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Head (1)</td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="12" style="width:94.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Eyes (1)</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="7" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Trunk (3)</td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:94.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Arms (4)</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="12" style="width:94.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="7" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:94.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="2" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Hands (4)</td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="12" style="width:94.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Legs (5)</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="7" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Internal (7)</td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:94.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Back (3)</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="12" style="width:94.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="7" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:94.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="2" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Neck (2)</td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="12" style="width:94.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Fingers (4)</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="7" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Feet (5)</td><td colspan="2" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td style="width:94.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Toes (5)</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="12" style="width:94.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="7" style="width:91.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:94.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="27" style="width:454.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Other (specify)</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"></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="2" style="width:91.25pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></td><td colspan="12" style="width:94.1pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="7" style="width:91.25pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td></tr><tr style="height:1.4pt"><td colspan="11" style="width:165pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top">Type of injury</td><td colspan="3" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Drowning (150)</td><td colspan="3" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Crushing (100)</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></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">Laceration (060/080)</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Burns & scalds (120)</td><td colspan="3" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Hernia (450)</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></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">Fracture (020/010)</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Electric shock (150)</td><td colspan="3" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Amputation (070)</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></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">Foreign Body (110/090)</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Abrasion (090)</td><td colspan="3" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Bruising (100)</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></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">Asphyxia (110/150/140)</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Strain & sprain (040)</td><td colspan="3" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="15" style="width:292.55pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Other (specify)</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"></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:133.8pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="5" 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"></td></tr><tr style="height:1.4pt"><td colspan="11" style="width:165pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top">Result of incident</td><td colspan="3" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Death</td><td colspan="3" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Serious injury</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></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">Minor injury</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Near miss</td><td colspan="3" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Temporary disability</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></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">Partial disability</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Permanent disability</td><td colspan="3" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Disappearance</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></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">Time off work</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="27" style="width:454.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Other (specify)</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"></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:133.8pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="5" 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"></td></tr><tr style="height:1.4pt"><td colspan="11" style="width:165pt; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top">Place of incident</td><td colspan="3" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Machinery spaces</td><td colspan="3" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Accommodation block</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></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">Galley</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Deck/cargo spaces</td><td colspan="3" style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Gangway/pilot ladder</td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></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">Wharf</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:133.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></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"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="27" style="width:454.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Other (specify)</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"></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:133.8pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="3" style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="9" style="width:130.95pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td style="width:6.2pt; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="5" 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"></td></tr><tr style="height:3pt"><td colspan="29" 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">Incident factors</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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="16" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Machinery and (mainly) fixed plant (1)</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"></td><td colspan="10" style="width:213.2pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Materials and substances (6)</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="27" style="width:454.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="16" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Mobile plant and transport (2)</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"></td><td colspan="10" style="width:213.2pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Environmental agencies (7)</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="27" style="width:454.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="16" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Powered equipment, tools and appliances (3)</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"></td><td colspan="10" style="width:213.2pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Animal, human and biological agencies (8)</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="27" style="width:454.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="27" style="width:454.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Non-powered hand tools, appliances and other equipment (4)</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="27" style="width:454.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></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"></td><td style="width:6.2pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td><td colspan="16" style="width:213.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Chemicals and chemical products (5)</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"></td><td colspan="10" style="width:213.2pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top">Other and unspecified agencies (9)</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"></td><td style="width:6.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"></td><td colspan="27" style="width:454.15pt; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"></td></tr><tr style="height:3pt"><td colspan="29" style="width:485.35pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Cause of injury/illness</td></tr><tr style="height:3pt"><td colspan="17" 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">Date left ship</td><td colspan="12" 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">Expected period of incapacity</td></tr><tr style="height:3pt"><td colspan="17" 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">Treatment given on board ship</td><td colspan="12" 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"></td></tr><tr><td colspan="29" style="width:485.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Part 5 - Explanation and Description State Cause and give names and addresses of any witnesses</td></tr><tr><td colspan="29" style="width:485.35pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td></tr><tr><td colspan="29" style="width:485.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Part 6 - Incident narrative</td></tr><tr><td colspan="29" style="width:485.35pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td></tr><tr><td colspan="29" style="width:485.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Part 7 - Action taken to prevent similar occurrences</td></tr><tr><td colspan="29" style="width:485.35pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"></td></tr><tr><td colspan="29" style="width:485.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Part 8 - Details of person completing report</td></tr><tr><td colspan="29" 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">Name</td></tr><tr><td colspan="17" style="width:237.25pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Position</td><td colspan="12" style="width:237.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top">Contact number</td></tr><tr><td colspan="27" 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">Signature</td><td colspan="2" 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">Date / /</td></tr><tr style="height:0pt"><td style="width:14.2pt"></td><td style="width:17pt"></td><td style="width:94.7pt"></td><td style="width:7.35pt"></td><td style="width:1.4pt"></td><td style="width:15.6pt"></td><td style="width:3.95pt"></td><td style="width:10.25pt"></td><td style="width:0.9pt"></td><td style="width:7.6pt"></td><td style="width:2.85pt"></td><td style="width:14.15pt"></td><td style="width:1.4pt"></td><td style="width:1.45pt"></td><td style="width:0.85pt"></td><td style="width:17.3pt"></td><td style="width:37.1pt"></td><td style="width:7.1pt"></td><td style="width:17pt"></td><td style="width:32.6pt"></td><td style="width:25.95pt"></td><td style="width:1pt"></td><td style="width:2.85pt"></td><td style="width:17pt"></td><td style="width:9.9pt"></td><td style="width:12.75pt"></td><td style="width:15.6pt"></td><td style="width:1.4pt"></td><td style="width:104.95pt"></td></tr></tbody></table>

Distinguishing numbers or marks of articles	Description of articles	Material of articles	Number of articles tested	Proof load applied	Date of test	Safe working load	Name and address of makers or suppliers of articles

Distinguishing numbers or marks of articles	Description of articles	Material of articles	Number of articles tested	Proof load applied	Date of test	Safe working load	Name and address of makers or suppliers of articles