VEII First Report

First Report of Incident

Validus Energy
This form is to be completed with facts known from the incident.
Lease/Location of Incident
If Other - Please describe
Date

MonthDayYear
Date
Time of Event

:HourMinutesAM/PM Option
Incident Type

InjurySpillAutoProperty DamageFireNear MissOtherLine Strike
Incident Level

For Information OnlyLevel 1Level 2Level 3
Short Description
Do Not Use Names
Type of Damage (save to add rows)
Type of Injury

NoneFirst AidRecordableLost TimeFatalityOther
Part of Body Injured (save to add rows)
Spill Type

OilProduced WaterChemicalOther Produced Fluid/MudOther
Quantity Spilled (Bbl)
Quantity Recovered (Bbl)
Operating Department

Admin Services/Land/OfficeDrillingCompletionsConstructionOperations/ProductionNot Validus RelatedMidstream
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

Browse Files

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Capture/Upload Photo(s)

Browse Files
DO NOT Upload photos showing blood or injuries. Cancelof
Upload Incident Report

Browse Files

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Upload Other Files

Browse Files

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Regulatory Reportable/Recordable?

YesNo
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
Why (save to add rows)
Corrective Action Item(s)
Corrective Action Completed

MonthDayYear
Date
Date Closed

MonthDayYear
Date
Remediation Costs
Notes
Cost Estimates provided by:

First NameLast Name
Should be Empty:

First Report of Incident

Investigation (EHS)