Preliminary Incident Notification Form Draft

• Preliminary Incident Notification

• TES-MS-1022

INCIDENT DETAILS

• Date of Incident

  Date

• Time of Incident

  Date

• Incident Location

• Product Line

  Stimulation

  Wireline

  Coiled Tubing

  McAlester Yard

• 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)

INJURED PERSON

• Employee Name

• Job Title

• Supervisors Name

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

• IMMEDIATE ACTIONS TAKEN (describe in detail)

• Add Pictures

  Media

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

• IMMEDIATE ACTIONS TAKEN (describe in detail)

• Add Pictures

  Media

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

• IMMEDIATE ACTIONS TAKEN (describe in detail)

• Add Pictures

  Media

• SUMMARY - TO BE COMPLETED BY THE HSSE PERSONNEL

• Person Completing Report

• Job Title

• Incident Injury Classification

  DAFWC

  Restricted/Transfer Case

  Medical Treatment Case

  First Aid Case

  N/A

• Quantity Contained ( Gallons )

• Quantity Outside Containment ( Gallons )