Preliminary Incident Notification Form

Preliminary Incident Notification Form

TES-HS-1005

Preliminary Incident Notification Form

Document Number: TES-HS-1005

Revision Level: 5.0

Release Date: 03/06/2014

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 Environmental Property Damage Vehicle Security Near Miss

  • Injury/Illness
  • Environmental
  • Property Damage
  • Vehicle
  • 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)

• TO BE COMPLETED BY THE HSSE PERSONNEL

• Person Completing Report:

• Phone #

• Incident Injury Classification:

  DAFWC

  Restricted/Transfer Case

  Medical Treatment Case

  First Aid Case

  N/A

• 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.