Injury Report Form

Injury Report Form
Please report all Injuries to the Spill and Incident Number - (306)-460-0179
Name*

First NameLast Name
Date of Injury*

MonthDayYear
Date
Time of Incident Reporting*

:HourMinutes
Division*

CompletionsConstructionDrillingOperations
Completions Area*

AB - CompletionsAB - Well ServicingSK - CompletionsSK - Well Servicing
Construction Area*

AB - ConstructionSK - Construction
Drilling Area*

AB - DrillingSK - Drilling
Operations Area*

AB - OperationsChauvin - OperationsSK - Operations - Avon Hill - Scott OsterholdSK - Operations - Coleville - Chris SolomonSK - Operations - Dodsland - Cory TurkSK - Operations - Hoosier - Trent MartinSK - Operations - Maintenance - James ElliottSK - Operations - Plato - Tyler Reid
Surface Location*
Downhole Location (if applicable)
Information
Estimated Time of Incident*

:HourMinutes
to
until :HourMinutes
Activity at time of spill*

Abandonment and ReclamationDrilling and CompletionsConstructionGeoPhysicalOperationsOther
Body Part Injured*

AbdomenBackChestEarsEyesFaceForeheadGroinHeadHipsLeft AnkleLeft Fingers and thumbLeft FootLeft ForearmLeft HandLeft KneeLeft LegLeft ShinLeft ShoulderLeftThighLeft ToesLeft Upper ArmLeft WristMouthMouth & TeethNeckRight AnkleRight ElbowRight Fingers and ThumbRight FootRight ForearmRight HandRight KneeRight LegRight ShinRight ShoulderRight ThighRight ToesRight Upper ArmRight WristScalpSkullVertebrae
Nature of Injury*

AbrasionAcoustic TraumaAmputationBruisesBurnConcussionCutDermatitisDislocationForeign BodyFractureFrostbiteGanglionHerniaLacerationPoisoningPunctureStrain / StrainUnconsciousness
Injury Cause*

AbsorbtionBlowoutCaught in between (crush point)Caught On (snagged / hung)Contact with (Radiation / Caustics / Toxins)Cut byElectric ShockEquipment FailureExplosionExtreme ColdExtreme HeatFall from Elevation to Lower LevelFall from same level (slip and fall / tripping)IngestionInhalationMechanical failureNoise ExposureOverstress / Overexertion / ErgonomicsPhysical AltercationPhysical conditionSlip (without falling)Sprayed with fluidsStruck against (running or bumping into)Struck by falling objectStruck by Flying objectStruck by moving object
Description of Incident including Pictures (Who, What, When, Where and Why)*
Pictures*

Take Picture / Upload Photo

Cancelof
Injured Persons Name*

First NameLast Name
Is injured worker a Teine worker?*

YesNo
Company Name of Injured person?*
Company Phone Number?*
Phone number of Injured Worker*
Persons Notified*

HSEForemanLead Operator
Treatment Type*

On site First AidOff Site Treatment Required
Treatment Administered By*

Medic on LocationSelf AdministeredSite Supervisor
Treatment Location*

Kindersley HospitalKerrobert HospitalEston HospitalOyen HospitalDrayton valleyOther
Should be Empty:

Injury Report Form

Information