Title Page
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Site conducted
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Date of Occurrence
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Time of Occurrence
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Details
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Shift
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Location/Site of Occurrence
Rig Number
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Reported by
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Position
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Employee Type
Incident Details
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Description of Incident
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Media
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Hazard Category
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Potential Impact Type
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Severity Matrix Table:
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Immediate action taken and initial investigation findings
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Has the risk been controlled?
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Are further actions required?
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Name of person assigned further actions
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Details of further action required
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Date actions to be completed by
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Signature
