Vehicle Accident

Vehicle Accident Report - Please Fill out Police Report & Submit

Day Of The Week*

Select

Time of Day*

24HR Format (HH:MM)

Reported By

First and last name

Select or enter value

Product Line/Division*

Select Main Division Experiencing Event

Select

Incident / Accident Details

Police Repot ID/#

Please Provide Police Report Number or email to HSE

Main Activity At Time of Event*

Select all that apply

Select

Loss Experienced*

Select

Injury / Illness Classification

N/A

Environmental Impact

N/A

Identify Material(s) discharged

Amount of Material Discharged

N/A

Incident Information

Client / Customer*

Select

Location of Incident*

Lease Location or Specific Area

Well Name/#

Please identify Well Information

Equipment / Unit #

Select all that apply including trailer #

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Lost Time/NPT (Hours)

Time lost due to incident

Field Supervisor

N/A

Lead Operator

Select

Incident Description

(use smartphone mic to verbally describe incident details if available)

Detailed Account Of The Event

Describe the incident/accident/event in detail

Property / Equipment / Material

List or identify the property, equipment, material damaged.

Damage Description

Describe the damage to property the property, equipment or material.

Third Party Damage

list or identity any 3rd party damage or loss

Cause of Damage

List or describe the substance inflicting the damage

Unsafe Acts

If Other Selected Please Explain

Select

Unsafe Conditions

Select

Management Deficiencies

N/A - Allow Investigation Team to determine

Severity of the Event*

Catastrophic

Very Serious

Serious

Minor

Frequency of Task*

Few times per job

Once per job

Occasionally during the week

Few times a Month

Injury Involved

Please check if Vehicle Accident involved any injuries

Name Of Injured Person

First Name, Last Name

Supervisors Name of Injured Person

Phone Number of Injured Person

Age of Injured Person

Job Title of Injured Person

Select or enter value

Division Injured Person is Employed

Select

Supporting Documents*

Documents required & provided with report; Sslect all that apply

Select

File Upload

Attach supporting photos & documents

Drag and drop files here or

Incident Analysis

Management Investigation Office Use only

Product Line Manger*

Please Select Your Product Line Manager

Select

Send me a copy of my responses

Incident / Accident Details

Incident Information

Crew Information

Incident Description

Contributing Causes

Risk Assessment

Injury Details

Supporting Evidence

Incident Analysis