Information

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

  • Time of Incident

  • Incident Location (Client Well Name)

  • Product Line

  • Incident Type

  • 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)

  • Was Injured Person seen at a Medical Facility?

  • IMMEDIATE ACTIONS TAKEN (describe in detail)

  • INFORMATION

  • Person Completing Report:

  • Phone #

  • Environmental Incident:

  • Quantity Contained (Gallons)

  • Quantity Outside Containment (Gallons)

  • Attach Photos

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

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