Near Miss/Conditions Incident Investigation Report
Scout Drilling LLC.
Department
*
Please Select
Drilling
Exploration
Report Type
*
Near Miss
Property Damage
Hazard
Commute
Category
*
Caught In/Under/Between
Struck Against/Contact
Slip/Trip/Fall - All Same Level
Fall from Elevation
Vehicle
Exposure - Chemical/Noise
Machine Involvement
Tool Hand-Power
Other
Category (other)
*
Date of Occurance
*
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Date Reported
*
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location
*
Description of Near Miss / Condition
*
Underlying Causes (select all that apply)
*
Inadequate Tools/Equipment/Furniture
Inadequate Maintenance
Leadership/Supervision
Work Standards
Inadequate Engineering/Design
Wear & Tear
Defective Tool
Inadequate Capability
Lack of Knowledge/Training
Lack of Skill/Training
Poor Work Procedures
Inadequate Purchasing
Misuse
Inadequate Inspection
Other
Underlying Causes (other)
*
Prevention (select all actions taken to prevent re-occurence)
*
Perform job safety analysis
Improve work procedures
Inform staff/supervisors of safe work procedures
Inform staff/supervisors of hazards
Instruction of persons involved
Reinstruction of persons involved
Improve personal protective equipment
Improve engineering/design
Improve inspection procedures
Tools, equipment, furniture, repair/replacement
Request ergonomic assessment
Request environment assessment
Correction of area
Installation of guard or safety devices
Recommend development of training materials
Recommend improvement of OH& Program
Refer to JOHS Committee for review and action
Other
Prevention (other)
*
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Witness Information
Witness Name
*
First Name
Last Name
Position / Occupation
*
Witness Position / Occupation
Phone Number
*
Witness Phone Number
Address
*
Street Address
Street Address Line 2
City
Please Select
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Alaska
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Connecticut
Delaware
District of Columbia
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Hawaii
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Louisiana
Maine
Maryland
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Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Street Address
*
Witness Address: Street Address Line 1
Street Address Line 2
Witness Address: Street Address Line 2
State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Witness Address: State
City
*
Witness Address: City
Zip Code
*
Witness Address: Zip Code
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Manager's Information
Regional/Area Manager Name
*
First Name
Last Name
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SHE Coordinator Information
SHE Coordinator Name
First Name
Last Name
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Emyployee Information
Employee Name
*
First Name
Last Name
Employee Phone Number
*
Please enter a valid phone number.
Employee Position
*
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Contractor's Information
Contractor's Name (if applicable)
First Name
Last Name
Contractor's Signature (if applicable)
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Report Originator's Information
Report Originator's Name
*
First Name
Last Name
Report Originator's Signature
*
Additional Comments
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Geo Stamp 1
Geo Stamp Data 1
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