Information
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COI District, Field:
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Location:
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Date:
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Prepared By:
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Description of Incident:
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Incident Type:
- Injury
- Occupational Illness
- Environmental Release
- Fire/Explosion
- Pressure/Well Control Event
- Personal Illness
- Security/Theft
- Equipment Damage
- Property Damage
- Equipment Failure
- Other
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Location of Incident:
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Occurred on company premises:
Where did incident occur
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If not on company premises, where did the incident occur?
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Location of Incident (Rig):
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Well/Site Name and Number:
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City:
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State:
- West Virginia
- Pennsylvania
- Ohio
- Kentucky
- Virginia
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County:
- Beaver
- Belmont
- Boyd
- Braxton
- Brooke
- Buchanan
- Cabell
- Carroll
- Columbiana
- Dickenson
- Doddridge
- Floyd
- Greene
- Guernsey
- Hancock
- Harlan
- Harrison
- Holmes
- Jefferson
- Johnson
- Knott
- Lawrence
- Letcher
- Lewis
- Lincoln
- Logan
- Marion
- Marshall
- Pleasants
- Magoffin
- Mahoning
- Martin
- McDowell
- Mingo
- Monongalia
- Ohio
- Pike
- Portage
- Preston
- Ritchie
- Stark
- Trumbull
- Tuscarawas
- Tyler
- Upshur
- Washington
- Wayne
- Wetzel
- Wyoming
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Date of incident and Time of Occurrence
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Person Involved:
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Relationship to COI:
- Employee
- Contractor Employee
- Member of the Public
- Other
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Supervisor Name and Contact Number of Stated Incident/Injured:
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Date/Time Shift Began:
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Witness(s) Name(s) and Contact Information:
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Immediate Action Taken:
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Reported By/Contact Information:
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Additional Comments:
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Please attach all corresponding incident reports/statements/pictures relating to incident.
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If you have any questions or need assistance please contact a member of our EHS Department.
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Kurt Kehl - 304-941-7773
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Kevin Patterson - 304-641-0551
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Matt Boggs - 304-406-2454
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Melissa Barker - 304-517-3731
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Kristi Evans - 304-406-4685
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Jessica Harley - 740-827-6490
