Chaparral Energy Incident Investigation Report

• Affected Employee

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

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