First Report of Incident

FIRST REPORT OF INCIDENT

TES-HS-1005

First Report of Incident

Document Number: TES-HS-1005

Revision Level: 6.0

Release Date: 05/27/2014

INCIDENT DETAILS

• Date of Incident

  Date

• Time of Incident

  Date

• Incident Location (Client Well Name)

• Product Line

  Select Stimulation Coiled Tubing Cased Hole Wireline Open Hole Wireline Maintenance Facility

  • Stimulation
  • Coiled Tubing
  • Cased Hole Wireline
  • Open Hole Wireline
  • Maintenance
  • Facility

• Incident Type

  Select Injury/Illness Spill/Release Property Damage Motor Vehicle Accident Security Near Miss

  • Injury/Illness
  • Spill/Release
  • Property Damage
  • Motor Vehicle Accident
  • Security
  • Near Miss

• INJURED PERSON (IP) DETAILS (ONLY COMPLETE IF REPORTING AN INJURY OR ILLNESS)

Employee name

• Employee Name

• Job Title

• Phone #

• Supervisors Name

• Phone #

• WITNESSES

Witnesses

• Employee Name

• Job Title

• Phone #

• INCIDENT DETAILS (Include information about activities being performed during incident)

• What chemical(s) or substance(s) was/were involved?

• For Injuries, was Axiom called? (877-502-9466)

  Yes

  No

  N/A

• Was Injured Person seen at a Medical Facility?

  Yes

  No

  N/A

• IMMEDIATE ACTIONS TAKEN (describe in detail)

• INFORMATION

• Person Completing Report:

• Phone #

• Environmental Incident:

• Quantity Contained (Gallons)

• Quantity Outside Containment (Gallons)

• Attach Photos

  Media

• DISTRIBUTION: Send completed form to local HSSE Coordinator for review and further distribution.