First Report of Incident
Validus Energy
This form is to be completed with facts known from the incident.
Lease/Location of Incident
Date
-
Month
-
Day
Year
Date
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
Auto
Property Damage
Fire
Line Strike
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)
Operating Department
Admin Services/Land/Office
Drilling
Completions
Construction
Operations/Production
Not Validus Related
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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of
Capture/Upload Photo(s)
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DO NOT Upload photos showing blood or injuries.
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of
Upload Incident Report
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of
Upload Other Files
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of
Investigation (EHS)
(Not needed for Initial Report)
Investigation Team (save to add rows)
Regulatory Reportable/Recordable?
Yes
No
Reported to (save to add rows)
Additional Information
Why (save to add rows)
Root Cause(s)
Corrective Action Item(s)
Corrective Action Completed
-
Month
-
Day
Year
Date
Internal/External Contacts Made (save to add rows)
Date Closed
-
Month
-
Day
Year
Date
Remediation Costs
Notes
Cost Estimates provided by:
First Name
Last Name
Save
Submit
Should be Empty: