Information
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Conducted on
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Prepared by
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Names of personnel involved
General Incident Information
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Select date
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Location
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Division
- Casing
- Lay Down
- Rack
- Rat Hole
- Special Services
- Shop
- Drilling
Customer Information (If Applicable)
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Customer (Continental, HESS, Whiting, ETC., if in transit please put N/A)
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Was the customer notified?
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If the answer to the previous question is 'Yes' please indicate the name, position and phone number of the customer representative notified
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Well Name
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Rig
Equipment Damage
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Does this incident involve equipment damage? (Do not complete this section if this is a motor vehicle accident). (If the answer is 'No' please proceed to next section)
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In your estimate does equipment damage appear to exceed $1,000.00?
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Please enter the asset number and description of equipment damaged (this includes 3rd party equipment, please exclude if this is a Motor Vehicle Accident)
Motor Vehicle Accident
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Is this a Motor Vehicle Accident? (If the answer is 'No' please proceed to next section)
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Were there 3rd party individuals or vehicles involved?
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If the answer to the previous question is 'Yes' please identify names of occupants of 3rd party vehicle and any contact information you have
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Please identify the type(s) of vehicle(s) involved. Please include (if known) Make, Model, Year, VIN, License Plate, Color, any previous damage, etc
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Please identify the name(s) and phone number(s) of any wittnesses
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Was Law Enforcement Contacted?
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If 'Yes' to previous question please identify which agency (State Patrol, County Sheriff, City Police, Federal Authorities, BIA, etc)
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Please enter the Case Number or Incident Report number from Law Enforcement (If available)
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Was anybody transported by ambulance away from the scene?
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If the answer to the previous question is 'Yes' please indicate the name(s) of the individuals transported
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Did the incident involve any Commercial Motor Vehicles?
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Please identify the Noble vehicle VIN Number
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Describe the Incident
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Who was driving the Noble vehicle?
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Please identify any other occupants of the Noble vehicle
Injured Employee
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Name (Please provide full legal name as well as nickname)
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Injured Employees contact phone number
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What is the employees job title?
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What was the employee doing at the time of injury?
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Please enter the employees date of hire (if known)
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Select date
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Please describe, in detail, what happened. Please include what contacted the employee, if equipment failed, etc.
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Did the injured worker or management contact Work Partners Triage? (1-800-359-5020)
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If 'No' to the previous question please explain why.
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Has the injured worker sought treatment beyond first aid?
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If 'Yes' to the previous question please enter the following
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Name of medical facility
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Name of treating medical provider
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Was this an Emergency Room visit?
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Was the injured employee admitted to the hospital?
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Enter the date of first medical treatment
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Body Part Injured
- Ankle
- Arm
- Back (Lower)
- Back (Middle)
- Back (Upper)
- Chest
- Ear
- Elbow
- Eye
- Face
- Finger
- Foot
- Groin
- Hand
- Head
- Hip
- Knee
- Leg
- Mouth
- Neck
- Nose
- Shoulder
- Stomach
- Toe
- Wrist
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Location of Body Part Injured
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Nature of Injury
- AIDS
- All Other
- All Other Cumulative Injuries
- All Other Occupational Diseases
- Amputation
- Angina Pectoris (Heart Disease)
- Asbestos
- Asphyxiation
- Black Lung
- Burn (s)
- Byssinosis
- Cancer
- Carpal Tunnel Syndrome
- Contagious Disease
- Contusion
- Crushing
- Dermatitis
- Dislocation
- Dust Disease (All other Pneumonocosiosis)
- Electric Shock
- Enucleation (Removal of Eye)
- Exposure to Bodily Fluid
- Foreign Body
- Fracture
- Freezing
- Hearing Loss (Traumatic Only)
- Heart Attack
- Heat Prostration
- Hernia
- Hypertension
- Infection
- Inflammation
- Lacerations
- Loss of Hearing - Progressive
- Mental Disorder
- Mental Stress
- Multiple Injuries Both Physical and Psychological
- Multiple Physical Injuries Only
- Needle Stick
- No Physical Injuries
- Poisoning - Chemical
- Poisoning - General (Not OD or Cumulative Injury)
- Poisoning - Metal
- Puncture
- Radiation
- Respiratory Disorders (Gases, Fumes, Chemicals)
- Rupture
- Severance
- Silicosis
- Sprain
- Strain
- Syncope (Fainting)
- Tendonitis
- VDT - Related Disease
- Vascular Loss
- Vision Loss
- Struck By
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If known please indicate medical advice given and medical treatment provided
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Has the employee had problems with this body part before?
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Additional Body Part Injured
- Ankle
- Arm
- Back (Lower)
- Back (Middle)
- Back (Upper)
- Chest
- Ear
- Elbow
- Eye
- Face
- Finger
- Foot
- Groin
- Hand
- Head
- Hip
- Knee
- Leg
- Mouth
- Neck
- Nose
- Shoulder
- Stomach
- Toe
- Wrist
-
Location of Body Part Injured
-
Nature of Injury
- AIDS
- All Other
- All Other Cumulative Injuries
- All Other Occupational Diseases
- Amputation
- Angina Pectoris (Heart Disease)
- Asbestos
- Asphyxiation
- Black Lung
- Burn (s)
- Byssinosis
- Cancer
- Carpal Tunnel Syndrome
- Contagious Disease
- Contusion
- Crushing
- Dermatitis
- Dislocation
- Dust Disease (All other Pneumonocosiosis)
- Electric Shock
- Enucleation (Removal of Eye)
- Exposure to Bodily Fluid
- Foreign Body
- Fracture
- Freezing
- Hearing Loss (Traumatic Only)
- Heart Attack
- Heat Prostration
- Hernia
- Hypertension
- Infection
- Inflammation
- Lacerations
- Loss of Hearing - Progressive
- Mental Disorder
- Mental Stress
- Multiple Injuries Both Physical and Psychological
- Multiple Physical Injuries Only
- Needle Stick
- No Physical Injuries
- Poisoning - Chemical
- Poisoning - General (Not OD or Cumulative Injury)
- Poisoning - Metal
- Puncture
- Radiation
- Respiratory Disorders (Gases, Fumes, Chemicals)
- Rupture
- Severance
- Silicosis
- Sprain
- Strain
- Syncope (Fainting)
- Tendonitis
- VDT - Related Disease
- Vascular Loss
- Vision Loss
- Struck By
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If known please indicate medical advice given and medical treatment provided
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Has the employee had problems with this body part before?
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Additional Body Part Injured
- Ankle
- Arm
- Back (Lower)
- Back (Middle)
- Back (Upper)
- Chest
- Ear
- Elbow
- Eye
- Face
- Finger
- Foot
- Groin
- Hand
- Head
- Hip
- Knee
- Leg
- Mouth
- Neck
- Nose
- Shoulder
- Stomach
- Toe
- Wrist
-
Location of Body Part Injured
-
Nature of Injury
- AIDS
- All Other
- All Other Cumulative Injuries
- All Other Occupational Diseases
- Amputation
- Angina Pectoris (Heart Disease)
- Asbestos
- Asphyxiation
- Black Lung
- Burn (s)
- Byssinosis
- Cancer
- Carpal Tunnel Syndrome
- Contagious Disease
- Contusion
- Crushing
- Dermatitis
- Dislocation
- Dust Disease (All other Pneumonocosiosis)
- Electric Shock
- Enucleation (Removal of Eye)
- Exposure to Bodily Fluid
- Foreign Body
- Fracture
- Freezing
- Hearing Loss (Traumatic Only)
- Heart Attack
- Heat Prostration
- Hernia
- Hypertension
- Infection
- Inflammation
- Lacerations
- Loss of Hearing - Progressive
- Mental Disorder
- Mental Stress
- Multiple Injuries Both Physical and Psychological
- Multiple Physical Injuries Only
- Needle Stick
- No Physical Injuries
- Poisoning - Chemical
- Poisoning - General (Not OD or Cumulative Injury)
- Poisoning - Metal
- Puncture
- Radiation
- Respiratory Disorders (Gases, Fumes, Chemicals)
- Rupture
- Severance
- Silicosis
- Sprain
- Strain
- Syncope (Fainting)
- Tendonitis
- VDT - Related Disease
- Vascular Loss
- Vision Loss
- Struck By
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If known please indicate medical advice given and medical treatment provided
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Has the employee had problems with this body part before?
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Additional Body Part Injured
- Ankle
- Arm
- Back (Lower)
- Back (Middle)
- Back (Upper)
- Chest
- Ear
- Elbow
- Eye
- Face
- Finger
- Foot
- Groin
- Hand
- Head
- Hip
- Knee
- Leg
- Mouth
- Neck
- Nose
- Shoulder
- Stomach
- Toe
- Wrist
-
Location of Body Part Injured
-
Nature of Injury
- AIDS
- All Other
- All Other Cumulative Injuries
- All Other Occupational Diseases
- Amputation
- Angina Pectoris (Heart Disease)
- Asbestos
- Asphyxiation
- Black Lung
- Burn (s)
- Byssinosis
- Cancer
- Carpal Tunnel Syndrome
- Contagious Disease
- Contusion
- Crushing
- Dermatitis
- Dislocation
- Dust Disease (All other Pneumonocosiosis)
- Electric Shock
- Enucleation (Removal of Eye)
- Exposure to Bodily Fluid
- Foreign Body
- Fracture
- Freezing
- Hearing Loss (Traumatic Only)
- Heart Attack
- Heat Prostration
- Hernia
- Hypertension
- Infection
- Inflammation
- Lacerations
- Loss of Hearing - Progressive
- Mental Disorder
- Mental Stress
- Multiple Injuries Both Physical and Psychological
- Multiple Physical Injuries Only
- Needle Stick
- No Physical Injuries
- Poisoning - Chemical
- Poisoning - General (Not OD or Cumulative Injury)
- Poisoning - Metal
- Puncture
- Radiation
- Respiratory Disorders (Gases, Fumes, Chemicals)
- Rupture
- Severance
- Silicosis
- Sprain
- Strain
- Syncope (Fainting)
- Tendonitis
- VDT - Related Disease
- Vascular Loss
- Vision Loss
- Struck By
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If known please indicate medical advice given and medical treatment provided
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Has the employee had problems with this body part before?
-
Additional Body Part Injured
- Ankle
- Arm
- Back (Lower)
- Back (Middle)
- Back (Upper)
- Chest
- Ear
- Elbow
- Eye
- Face
- Finger
- Foot
- Groin
- Hand
- Head
- Hip
- Knee
- Leg
- Mouth
- Neck
- Nose
- Shoulder
- Stomach
- Toe
- Wrist
-
Location of Body Part Injured
-
Nature of Injury
- AIDS
- All Other
- All Other Cumulative Injuries
- All Other Occupational Diseases
- Amputation
- Angina Pectoris (Heart Disease)
- Asbestos
- Asphyxiation
- Black Lung
- Burn (s)
- Byssinosis
- Cancer
- Carpal Tunnel Syndrome
- Contagious Disease
- Contusion
- Crushing
- Dermatitis
- Dislocation
- Dust Disease (All other Pneumonocosiosis)
- Electric Shock
- Enucleation (Removal of Eye)
- Exposure to Bodily Fluid
- Foreign Body
- Fracture
- Freezing
- Hearing Loss (Traumatic Only)
- Heart Attack
- Heat Prostration
- Hernia
- Hypertension
- Infection
- Inflammation
- Lacerations
- Loss of Hearing - Progressive
- Mental Disorder
- Mental Stress
- Multiple Injuries Both Physical and Psychological
- Multiple Physical Injuries Only
- Needle Stick
- No Physical Injuries
- Poisoning - Chemical
- Poisoning - General (Not OD or Cumulative Injury)
- Poisoning - Metal
- Puncture
- Radiation
- Respiratory Disorders (Gases, Fumes, Chemicals)
- Rupture
- Severance
- Silicosis
- Sprain
- Strain
- Syncope (Fainting)
- Tendonitis
- VDT - Related Disease
- Vascular Loss
- Vision Loss
- Struck By
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If known please indicate medical advice given and medical treatment provided
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Has the employee had problems with this body part before?
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Is the injured employee an SSE?
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How many employees on location are SSE?
- 1
- 2
- 3
- 4
- 5
- 0
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Was Post-Incident Drug and/or Alcohol Testing Completed?
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If 'Yes' to previous question please enter names of employees tested
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If 'No' to previous question please indicate why
Witness Information
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Witnesses (Please enter names and phone numbers of witnesses, please add any other information you can identify about the witness such as place of employment, etc)
Corrective Actions
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Please describe in detail what was done to immediately remedy the situation
Please place photos here
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Add media
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Please forward the following information to the Safety Director:
TDR's
JSA's from the job
Witness statements
Medical documentation
Employee
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I wish to seek medical treatment
Employee Signature
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Add signature
Person completing this Preliminary Incident Report Signature
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Add signature
