- Lost Time Accident
- Restricted Work Case
- Medical Treatment Only
- First Aid
- Near Miss
- Safety Specialist
List the affected employees name.
Affected employees sex
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?
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)?
How many total witness statements are there?
Was personal protective equipment being used?
Describe, step-by-step the events that led up to the incident?
Why did this incident happpen?
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?