Chaparral Energy Incident First 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.

• Was the employee treated in the emergency room?

  Select Yes No

  • Yes
  • No

• If "Yes," was the employee hospitalized over night as an in-patient?

  Select Yes No

  • Yes
  • No

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

• List the date visited by physician or hospital.

  Date

• Witness Name(s)

• 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?

• Pictures of Injury

  Media

• Person Reporting this Incident.

• Date & Time of Reporting this incident.

  Date