Title Page
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Conducted for (name of Company only)
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Conducted on
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Prepared by
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Location
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Chaparral Energy Personnel on Location
Personal Information
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Workers name
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Type of incident
- Property Damage
- Injury
- Illness
- Fatality
- Heat Stress
- Other
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If "other" is selected or more information is needed about the incident, please explain.
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Job title
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Length of employment
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Length of time in current role
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Workers supervisors name
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Was the supervisor present during the incident?
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Date and time of incident
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Location of incident
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Date reported to Chaparral Energy
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Who was notified at Chaparral Energy?
Incident Information
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Task being performed?
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Was the worker Authorized/Licensed/Certified to perform this task?
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Describe how the incident occurred?
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What happened?
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Why did it happen?
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Was the worker wearing appropriate PPE/seatbelt etc.?
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Is there any reason to question the validity of this incident?
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What do you think could be done to prevent a similar incident?
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Was a safety briefing conducted prior to work starting?
- Yes
- No
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If No, why? If Yes, show proof i.e. picture of JSA etc.
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Picture
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Was this issue discussed in the briefing?
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If No, why? If Yes, why was protocol not followed?
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Incident Pictures
Witness information
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Name
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Title
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Please explain what happened in your/their own words
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Name
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Title
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Please explain what happened in your/their own words
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Name
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Title
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Please explain what happened in your/their own words
Treatment
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Affected/possibly affected body parts
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Type of treatment
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Hospital/Doctor/Medical facility info.
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Additional comments or concerns regarding this incident.
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Safety Specialist
