First Report

• First Report

• Prepared by

• Location
  Address

Description

• Title Format: Property Name/Incident Type/Company Name-Brief Description/Date

• Title of Incident

• The Description the the KMI must include the Pad Name and incident date, relevant facts such as spill volume, piece of failed equipment, company name ( and contracting company if not working directly for CHK), reason for failure etc. Please answer the 5 W's (Who, What, When, Where and Why) when filing out the description of the incident. Do Not Include: employee names, rumors, hearsay and guesses etc.

• Incident Description

Incident Occurrence

• Injury - Any physical damage to he body caused by an incident involving anyone ( including contractors, vendors, or members of the public) on company premises, operating company equipment or in the course of company business.

• Illness/Injury Reported?

  Yes

  No

• Agency Information

Agency

• Agency Name:

• Agency contact (name):

• Phone number:

• Date reported to agency:

  Date

• Time reported to agency:

  Date

• External agency report number:

• Injured person transported by ambulance?

  Yes

  No

• Occupational Illness - Any abnormal condition or disorder caused by exposure to environmental factors.

• Illness/Injury Reported?

  Yes

  No

• Agency Information

Agency

• Agency Name:

• Agency contact (name):

• Phone number:

• Date reported to agency:

  Date

• Time reported to agency:

  Date

• External agency report number:

• Injured person transported by ambulance?

  Yes

  No

• Environmental/Atmospheric Release

• Name of Chemical Released

• Chemical Class

• Amount Released

• Release Source

  Select Commercial Carriage Vehicle Owned Vehicle Primary Waste Treatment Storage Vessel Flare Stack Pipeline Production Vessel Other

  • Commercial Carriage Vehicle
  • Owned Vehicle
  • Primary Waste Treatment
  • Storage Vessel
  • Flare Stack
  • Pipeline
  • Production Vessel
  • Other

• Released To

  Air

  Contained

  Ground

  Water

• Release Caused By

  Select Corrosion Equipment Malfunction Erosion Human Error Other Pipeline Failure Weather - Freezing Weather - Lightning Well Control

  • Corrosion
  • Equipment Malfunction
  • Erosion
  • Human Error
  • Other
  • Pipeline Failure
  • Weather - Freezing
  • Weather - Lightning
  • Well Control

• Fire/Flammable Atmosphere

• Fire/Explosion Reported?

  Yes

  No

• Agency Information

Agency

• Agency Name:

• Agency contact (name):

• Phone number:

• Date reported to agency:

  Date

• Time reported to agency:

  Date

• External agency report number:

• Pressure Event

• Equipment Failure

• Weather conditions:

  Select Clear Haze Rain Snow Ice Wind Flood Fog Hail Lightning Sleet Tornado Hurricane Smog

  • Clear
  • Haze
  • Rain
  • Snow
  • Ice
  • Wind
  • Flood
  • Fog
  • Hail
  • Lightning
  • Sleet
  • Tornado
  • Hurricane
  • Smog

• Type of equipment failure:

• Equipment:

• Manufacturer:

• Serial Number:

• Commission Date:

• Injured person transported by ambulance

  Yes

  No

• Well Control Event

• Property Damage

• Weather conditions:

  Select Clear Haze Rain Snow Ice Wind Flood Fog Hail Lightning Sleet Tornado Hurricane Smog

  • Clear
  • Haze
  • Rain
  • Snow
  • Ice
  • Wind
  • Flood
  • Fog
  • Hail
  • Lightning
  • Sleet
  • Tornado
  • Hurricane
  • Smog

• Property damage reported?

  Yes

  No

• Agency Information

Agency

• Agency Name:

• Agency contact (name):

• Phone number:

• Date reported to agency:

  Date

• Time reported to agency:

  Date

• External agency report number:

• Notice of Violation

• Motor Vehicle Accident

• Weather conditions:

  Select Clear Haze Rain Snow Ice Wind Flood Fog Hail Lightning Sleet Tornado Hurricane Smog

  • Clear
  • Haze
  • Rain
  • Snow
  • Ice
  • Wind
  • Flood
  • Fog
  • Hail
  • Lightning
  • Sleet
  • Tornado
  • Hurricane
  • Smog

• Injured person transported by ambulance?

  Yes

  No

• Agency Information

Agency

• Agency Name:

• Agency contact (name):

• Phone number:

• Date reported to agency:

  Date

• Time reported to agency:

  Date

• External agency report number:

• Security/Theft

• Security concern:

  Select Alarms Drug and Alcohol Theft Workplace Violence Break and Enter Site / Facility Vandalism Computer Theft

  • Alarms
  • Drug and Alcohol
  • Theft
  • Workplace Violence
  • Break and Enter
  • Site / Facility
  • Vandalism
  • Computer Theft

• Agency Information

Agency

• Agency Name:

• Agency contact (name):

• Phone number:

• Date reported to agency:

  Date

• Time reported to agency:

  Date

• External agency report number:

• Agency Inspection

• Water Source Complaint

Incident Occurrence

• Date of occurrence

  Date

• Time of occurrence

  Date

Location of Incident

• Well/Site Name

• Property Number

• State

  West Virginia

  Pennsylvania

  Ohio

• County

• City

• Postal/Zip Code

• Location
  Address

• Rig Name/Number

• Occurred on Company Premises

  Yes

  No

Activity and Task

• Activity

  Select Completion Disposal Drilling Driving Pipeline Production Transportation Treatment/Compression Other

  • Completion
  • Disposal
  • Drilling
  • Driving
  • Pipeline
  • Production
  • Transportation
  • Treatment/Compression
  • Other

• Task

Person(s) Involved

• Person Involved

Information of Person Involved

• Name

• Company Name

• Relationship to Chesapeake Energy

  Employee

  Contractor Employee

  Third Party Service Company

  Member of the Public

  Other

• Phone Number

• Supervisor Name

• Supervisor Phone Number

• Date and Time Shift Began

  Date
Witness Information

• Witness Name

• Relationship of Witness

• Witness Phone Number

Additional Information

• Immediate Action Taken

• Reported By

• Contact Information

• Additional Comments