Form BSEE-0143 FACILITY/EQUIPMENT DAMAGE REPORT

U.S. Department of the Interior OMB Control Number: 1014-0022

Bureau of Safety and Environmental Enforcement (BSEE) OMB Approval Expires: 08/31/2017

FACILITY/EQUIPMENT DAMAGE REPORT

Use this form to submit the damage report required by 30 CFR 250.192. Send completed form via e-mail or telefax within 48 hours after you complete your initial evaluation of the damage. Submit monthly reports thereafter and immediately whenever damage or estimated return to service information submitted in previous reports changes. In the final report, provide the date the item was returned to service. Submit the report to:
GOMR E-MAIL: EVACSTATS@BSEE.gov TELEFAX: Primary - (504) 736-5796 or (Alternate) - (504) 736-2426	POCSR E-MAIL: damagereport@bsee.gov TELEFAX: (805) 389-7592		AKOCS E-MAIL : BSEEAlaskaReports@bsee.gov TELEFAX: (907) 334-5302
Or telefax BSEE Headquarters (if the appropriate regional office is closed) - (703) 787-1093
GENERAL INFORMATION
Company name:		Event/Event date:
Contact:		Telephone number:
Report date:		Report time:

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 rapidly assess damage and project any disruption of oil and gas supplies from the OCS. 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 3 hours for the initial response, and estimated to average 1 hour per updated 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-0143 (Aug/2014 - Supersedes all previous versions of this form which may not be used.) Page 1 of 2

FACILITY/EQUIPMENT DAMAGE REPORT
Facility Name ◊	OCS Area	OCS Block / Lease	Damage Type #	Damage Description +	Initial Damage Assessment Φ	Production Rate at Time of Shut-In (BPD and/or MMCFPD)	Cumulative Production Shut-In (BPD and/or MMCFPD)	Estimated Time to Return to Service (days) *

◊ If the damaged facility is a pipeline, provide the BSEE pipeline segment number.

# Provide the type of damage (e.g., platform or other facility, production equipment, pipeline).

+ Use separate sheet if needed.

Φ Either major, medium, or minor.

* Need not be provided until availability of hardware and repair capability has been established (not to exceed 30 days from initial report).

CERTIFICATION: I certify that the information submitted is complete and accurate to the best of my knowledge. I understand that making a false statement may subject me to the criminal penalties of 18 U.S.C. 1001.

Name and Title: ________________________________________ Date: ________________________

BSEE Form BSEE-0143 (Aug/2014 – Supersedes all previous versions of this form which may not be used.) Page 2 of 2