BSEE-0011 Internet-Based Safety and Environmental Enforcement Repo

U.S. DEPARTMENT OF THE INTERIOR OMB Control No. 1014-xxxx

Bureau of Safety and Environmental Enforcement (BSEE) OMB Expiration Date: xx/xx/xxxx

iSEE

Internet-Based Safety and Environmental Enforcement Reporting System

Please provide as much information as you can about the suspected violation or noncompliance, as well as the location. The iSEE does not require you to provide personal information. You can remain anonymous. However, if you provide contact information, we can contact you back to ensure there is enough detail in your report to enable BSEE to take appropriate action.

Last Name: ____________________________________ First Name: _________________________________________

Email Address: __________________________________________ Phone Number: ____________________________

Category of Information being reported:

Safety of Personnel/Property Environmental Marine Trash and Debris Injured or Dead Protected Species Discovery of Shipwreck Other _______________________________________ _______________________________________________________________________________________________

Region: Gulf of Mexico Pacific Alaska/Artic

Location Information if Known: Company Name: ________________________________________________________

Area Block: ___________ Lease Number: __________ Production Facility Name: ____________________________

Drilling Rig Name: _________________________ GPS Coordination Latitude and Longitude: ___________________

Date of Offense: __________________ Other: ____________________________________________________________

REPORT: Violations of Lease Stipulations; Noncompliance with environmental mitigation measures; Noncompliance with conditions of approval on a permit; Noncompliance with NPDES permits. Examples: Bypassing oil spill prevention equipment; Disabling required safety equipment; etc.

Please describe in detail the problem or event:

DO NOT REPORT:

Emergencies and other sudden threats to public health, such as: Accident/Injuries/Deaths; Oil/chemical spills

Report an incident using BSEE Incident Reporting http://www.bsee.gov/Inspection-and-Enforcement/Accidents-and-Incidents/Incident-Investigations/

Report an oil spill or chemical discharge online to the National Response Center http://www.nrc.uscg.mil/ or call

1-800-424-8802.

PRIVACY ACT STATEMENT: The iSEE Reporting System website is a free service that provides the ability for the electronic reporting of suspected VIOLATIONS of, or NONCOMPLIANCE with, any and all safety or environmentally-related laws or regulations, as well as any VIOLATIONS of or NONCOMPLIANCE with any associated lease, plan, or permit requirements that occur offshore. All requested personal information on the violation form is voluntary; however, some personal information may be necessary in order to contact you if an investigation takes place. Any information provided on the violation form will be used to aid in the investigation of suspected VIOLATIONS of, or NONCOMPLIANCE with, any and all safety or environmentally-related laws or regulations, as well as any VIOLATIONS of or NONCOMPLIANCE with any associated lease, plan, or permit requirements that occur offshore. The BSEE will not share personal information provided with third parties for any reason. Please review the BSEE Privacy Policy for how information is handled: http://www.bsee.gov/Privacy-BSEE/.

Paperwork Reduction Act of 1995 (PRA) Statement: The PRA (44 U.S.C. 3501 et seq.) requires us to inform you that BSEE collects this information to ensure that facility management is knowledgeable of the incident of noncompliance issued; corrective action is taken in a reasonable period of time; and for component or facility shut-in enforcement actions, that the identified component or facility is not returned to operation without the prior notice to the appropriate BSEE office. Responses are mandatory (43 U.S.C. 1331 et seq.). No proprietary information is collected. An agency may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a currently valid OMB Control Number. Public reporting burden for this form is estimated to average 1.5 hours per response, including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. You may direct comments regarding the burden estimate or any other aspect of this form to the Information Collection Clearance Officer, Bureau of Safety and Environmental Enforcement, 381 Elden Street, Herndon, VA 20170.

BSEE Form BSEE-0011 (Mo/Year - Supersedes all previous editions of this form which may not be used.) Page 1 of 1