Information

  • Incident Number

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Personal Information

  • Name

  • Address

  • Title

  • Length of Employment

  • What time and date did the incident occur?

Type of Incident

  • What type of incident is it?

  • Complete form and turn in to HSE.

  • Complete form and turn in to HSE so a Safety Alert can be created.

  • Is the damage to Third Party Equipment or Terra Equipment?

  • Is the Property Damage Minor,Significant, or Major?

  • Limit possible harm to people and fill out report within 6 hours with Superintendent.

  • Limit possible harm to people and fill out report within 2 hours with Superintendent.

  • Limit possible harm to people and Superintendent must report to site within 2 hours

  • Was the spill Minor,Significant, or Major?

  • What material was spilled?

  • Clean spill,call Regional HSE Coordinator, forward Incident Report to HSE Manager.

  • What material was spilled?

  • Clean spill,call Regional HSE Coordinator, forward Incident Report to HSE Manager. Notify Rig Manager

  • What material was spilled?

  • Contain and Notify Rig Manager
    Superintendent must report to location within 2 hours

  • Was the injury a Minor, Significant, or Major as defined in the Incident Response flow Diagram?

  • What part of the Body was injured?

  • Administer First-Aid, call Regional HSE Coordinator, forward Incident Report to HSE Manager.

  • What part of the Body was injured?

  • Name of Doctor and Treating Facility with address.

  • Contact Superintendent Immediately.
    Fill out Report with in 2 hours.
    Contact HSE within 8 hours

  • What part of the Body was injured?

  • Name of Doctor and Treating Facility with address.

  • Contact EMS, Notify Rig Manager Immediately.
    Contact HSE and Superintendent with Immediately.
    HSE will contact HSE manager Immediately.
    Fill out report within 2 hours

Incident Specifics

  • What is the specific location of the incident?

  • Who was the incident reported to, what time was it reported and what date was it reported?

  • What Phase of the Employee's Work day did the incident occur?

  • Describe how the Incident occurred.

Incident Sequence.

  • Injury event

  • Incident Event

  • Preceding event # 1

  • Preceding event #2 and #3 ect.

Task and Activity at time of Incident

  • General type of Task

  • Specific Activity

  • Who was the employee working with?

  • What is the Attitude of the Employee?

  • Is the employee directly or indirectly supervised

  • Was the Supervisor on site at the time of incident?

  • Casual factors

  • Corrective actions that have or will be taken

  • Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.