First Report of Incident
Validus Energy
This form is to be completed with facts known from the incident.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Lease/Location of Incident
If Other - Please describe
Time of Event
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Incident Type
Injury
Spill
Property Damage
Fire
Near Miss
Line Strike
Theft/Security
Other
Incident Level
For Information Only
Level 1
Level 2
Level 3
Short Description
Do Not Use Names
Type of Damage (save to add rows)
Type of Injury
None
First Aid
Recordable
Lost Time
Fatality
Other
Part of Body Injured (save to add rows)
Spill Type
Oil
Produced Water
Chemical
Other Produced Fluid/Mud
Other
Quantity Spilled (Bbl)
Quantity Recovered (Bbl)
Department Name
Officer's Contact Information
Police Report Number
Approximate Cost
Operating Department
Admin Services/Land/Office
Drilling
Completions
Construction
Operations/Production
Not Validus Related
Midstream
Person Reporting
Person Reporting Email
example@example.com
Company(s) Involved/ Supervisor Name/ Phone # (save to add rows)
Rig Number
People Involved (save to add rows)
Describe what happened
Record what happened and subsequent factors
Witness(s) Company/ Phone # (save to add rows)
Upload Witness Statements
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Capture/Upload Photo(s)
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DO NOT Upload photos showing blood or injuries.
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Upload Incident Report
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Upload Other Files
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Regulatory Reportable/Recordable?
Yes
No
Reported to (save to add rows)
Internal/External Contacts Made (save to add rows)
Additional Information
Investigation (EHS)
(Not needed for Initial Report)
Investigation Team (save to add rows)
Root Cause
Animal
Contractor Error
Corrosion
Employee Error
Erosion
Facility Design
Mechanical Failure
Weather
Why (save to add rows)
Corrective Action Item(s)
Corrective Action Completed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date Closed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Remediation Costs
Notes
Cost Estimates provided by:
First Name
Last Name
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Submit
Should be Empty: