Attachment_6-Incident_Report_Form.pdf

For Industry Funded Scallop:

OMB #: 0648-0593

Expiration Date: 10/31/18

NORTHEAST FISHERIES OBSERVER PROGRAM

INCIDENT REPORT INSTRUCTIONS

Updated 01/04/17

The Incident Report is applicable to Northeast Fisheries Observer Program (NEFOP) Observers, Industry Funded Scallop (IFS) Observers, and At-Sea Monitors (ASM). As this report contains sensitive information it will not be publicly available unless all sensitive information is redacted. Please read the instructions before filling out the report to ensure all required information is included.

The Office of Law Enforcement (OLE) has provided a hotline number (1-800-853-1964) for the reporting of urgent/time sensitive issues that do not require immediate response and are not emergency situations. If observers/monitors have been assaulted, threatened with assault, or are in a situation that requires immediate response, they should call 911. If you have reported an incident to the OLE hotline number or 911, you are still required to complete and submit an incident report.

Filling Out the Report Please note, this report serves as a written affidavit of the incident, therefore, it is essential that the individual reporting the event complete the report. No other parties (program manager, area coordinator, etc.) should complete this report on behalf of an observer or ASM. All incidents must be reported within 12 hours after the incident occurred or within 12 hours of landing, depending on which is applicable. Please note, all incidents, including mishaps (minor sprains, strains, cuts, abrasions) and serious injuries must be reported.

Each data field is specific to a particular element (e.g., vessel name, incident location, etc.), please do not enter alternate information in the data fields. If you have additional information not listed as a data field you would like to include, please add those details in the "Incident Description" field. If a specific field is unknown, please leave it blank.

If the event occurs over the course of several days, enter the last or most recent associated date in the "Incident Date" field and include the other dates in the "Incident Description" field.

Observer/ASM ID or Trip ID If the incident occurred on a trip, provide the trip ID, if the incident did not occur on a trip (trip refusal, etc.) provide your identification ID (i.e., Observer or ASM ID).

Position Title Please select your position title from the drop down list. The choices include; NEFOP Observer, Industry Funded Scallop (IFS) Observer, At-Sea Monitor (ASM), FSB Staff Member, or Provider Staff Member.

Employer Name Please select your employer from the drop down list. Choices include; A.I.S, Inc. (AIS), East West Technical Services (EWTS), Fathoms Research, MRAG Americas Inc. (MRAG), or NMFS, FSB.

Incident Type Please select the type of incident from the drop down list. Please note, options may be only applicable to certain positions (i.e., NEFOP, IFS, ASM), please be sure you are selecting the correct incident type for your position. The choices include; assault, captain did not show to vessel at arranged time, concerns about safety, death of crew member, difficulty in setting up trip, discard of legal sized groundfish, drug/alcohol use of concern of use, failed to provide equal accommodations, failed to provide reasonable assistance, fire, flooding, gear tampering, gear theft, grounding of vessel, harassment, injured crew member, injured observer, interference, intimidation, MARPOL violation, Pre-Trip Notification System (PTNS) non-compliance, notification non-compliance (non-PTNS trips), refusal, safety deficiency, stability concerns, unsafe vessel operation, and other.

Please direct any questions to Sara Weeks (508) 495-2227 or Amy Martins (508) 495-2266.

Attachment 6

EA133F-17-RP-1824

SECTION J

INCIDENT REPORT

Name Last, First

Home Address & Phone Number

Observer/ASM ID or Trip ID Position Title

Incident Location (Port, Town, State) Incident Date

Vessel Name Vessel Permit Number

Vessel Hull Number

VTR Serial Number

Employer Name Names of Persons Involved

Incident Type

Provide a description of the incident with as much detail as possible. Include date, location, time, persons involved, exact quotes/statements, and other pertinent information.

I declare under penalty of perjury that the foregoing is true and correct.

Signature Date

Attachment 6

EA133F-17-RP-1824

SECTION J