VEII First Report

First Report of Incident

Validus Energy
This form is to be completed with facts known from the incident.
For all vehicle related incidents use the Validus Energy MVA Report
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Lease/Location of Incident
If Other - Please describe
Time of Event

:HourMinutesAM/PM Option
Incident Type
Incident Level
Short Description
Do Not Use Names
Type of Damage (save to add rows)
Type of Injury

Other
Part of Body Injured (save to add rows)
Spill Type

Other
Quantity Spilled (Bbl)
Quantity Recovered (Bbl)
Department Name
Officer's Contact Information
Police Report Number
Approximate Cost
Operating Department
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?
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
2 digit month, 2 digit day, 4 digit yearDate
Date Closed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Remediation Costs
Notes
Cost Estimates provided by:

First NameLast Name
Should be Empty:

First Report of Incident

Investigation (EHS)