BlackRock Services Incident Report

• Affected Employee

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Personal Information

• What is the nature of the incident?

  Equipment damage

  vehicle accident

  injury

• Employee Name

• Employee Social Security Number

• Employee Date of Birth

• Employee Address

• Children < 18

• Employee Phone Number

• Employee Marital Status

  Select single married

  • single
  • married

• Wage

• Job Description

• Employees Hire Date

• Equipment #

• Name of Employees Supervisor

• Date and Time of Incident

  Date

• Location of Incident

• What is the date this incident was reported to the employer?

  Date

• Is the employee likely to lose more than 3 calendar days of work?

  Yes

  No

  N/A

• Was this a lost time incident?

  Yes

  No

  N/A

• What is the last day the employee worked?

  Date

• What time did the work shift begin?

  Date

• What date did the employee return to work?

  Date

• Briefly describe how the incident occurred.

• Type of injury/possible injury

• List parts of body affected/possibly affected.

• List the name/address/phone # of treating physician or hospital?

• List the date visited by physician or hospital.

  Date

• Witness Name & Witness Statement

• Witness Phone Number

• Was the employee wearing the appropriate safety equipment?

  Yes

  No

  N/A

• Is there any reason to question the validity of this incident?

  Yes

  No

  N/A

• Is there any additional comments or concerns regarding this incident?

• What do you think can be done to prevent a similar incident?

• Person Reporting this Incident.

• Date & Time of Reporting this incident.

  Date

Vehicle Accidents Only

• Employee Name

• What is the BlackRock Services vehicle number?

• Employees Supervisor

• Date & Time of the Incident

  Date

• Weather/Road Conditions

  Select clear foggy rainy snowy icy

  • clear
  • foggy
  • rainy
  • snowy
  • icy

• Accident Location

• Witness Name

• Witness Phone Number

• 2nd Party Name

• 2nd Party Address

• 2nd Party Phone Number

• 2nd Party Vehicle Make

• 2nd Party Vehicle Model & Year

• 2nd Party License Plate Number

• List the 2nd Party's Insurance Company.

• List the 2nd Party's Insurance Phone Number

• How many passengers were inside the vehicle at the time of the accident?

• List the Police Officers Name.

• List the Police Department Name & Phone Number.

Witness Statements

• Witness Name

• Witness Age

• Witness Phone Number

• Witness Employer

• I saw the incident.

• To the best of my knowledge the incident occurred in the following manner:

• I did not see the incident.

• Information that was given to me indicates the incident occurs as followed:

• I have no knowledge of the incident.

• Additional Comments/Pertinent Information

• Witness Signature

  Sign

• Date & Time

  Date

Incident Investigation

• This is a report of:

  Select Lost Time Accident Restricted Work Case Medical Treatment Only First Aid Near Miss

  • Lost Time Accident
  • Restricted Work Case
  • Medical Treatment Only
  • First Aid
  • Near Miss

• List the date of the incident.

  Date

• This investigation was prepared by :

  Select Employee Supervisor Safety Specialist

  • Employee
  • Supervisor
  • Safety Specialist

• List the affected employees name.

• Affected employees sex

  male

  female

• What is the affected employees age?

• Where is the affected employees office location?

• What was the affected employees job title at the time of the incident?

• What body parts are affected or would have been affected from this incident?

• What is the nature of the injury or possible injury?

• What is this employees work status?

  Full Time

  Temporary

  Contract

• How many months or years has the employee been with Chaparral Energy?

• How many months or years has the employee been doing this job?

• What is the exact location of the incident?

• What was the exact time of the incident?

• How many hours did the affected employee work on the day of the incident?

• How many total hours did the affected employee work in the 7 days prior to the incident?

• When was the affected employees last day off?

• What are the names of witnesses (If any)?

• Date & Time Witness was Interviewed

  Date

• How many total witness statements are there?

• Incident Photographs

  Media

• Incident Map or Drawings

  Drawing

• Was personal protective equipment being used?

  Yes

  No

  N/A

• Describe, step-by-step the events that led up to the incident?

• Why did this incident happpen?

  Unsafe Workplace Conditions

  Unsafe Acts

• When did the unsafe workplace condition's exist? Before starting work, during work, never noticed anything unsafe etc.

• Did you know you were acting/performing/working in an unsafe manner? If so, why?

• Did you notice the hazard prior to the incident? If so, did you tell someone about it? If yes, describe exactly what was said or done.

• Have their been similar incidents or near misses prior to this one?

• What would you do to prevent this incident from happening again?

• What has been done to prevent this incident from happening again?

• Person who conducted the investigation

  Sign

• Job Title