MVA Incident Report
Validus Energy
This form is to be completed with facts known from the MVA.
Location
*
Date of Accident
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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
Validus Employee Involved
*
First Name
Last Name
Vehicle (s) Involved (save to add rows)
*
Operating Department
*
Admin Services/Land/Office
Drilling
Completions
Construction
Operations/Production
Not Validus Related
Midstream
Describe what happened
*
Record what happened and subsequent factors
Incident Level
*
Validus Damage Only
Validus Damage w/Employee Injury
3rd Party Damage- No Injury
3rd Party Damage and Injury
Non Employee Related - FIO
Describe Injuries
Transported by Ambulance?
No
Yes - Employee
Yes - Third Party
3rd Parties Involved/ address/ Phone # (save to add rows)
3rd Party Insurance Information
Witness(s) / Phone # (save to add rows)
Upload Witness Statements
Browse Files
Cancel
of
Type of Damage (save to add rows)
*
Capture/Upload Photo(s)
Browse Files
DO NOT Upload photos showing blood or injuries.
Cancel
of
Police Called?
Yes
No
Responding Officer
Upload Police Report
Browse Files
Cancel
of
Reported to:
Additional Information
Person Completing Report
*
Person Completing Report Email
*
example@example.com
Cause
Human Error
Mechanical Failure
Animal Strike
Distracted Driving
Weather
Validus Employee At Fault?
Yes
No
Vehicle Repair Location
Repair Estimates provided by:
First Name
Last Name
Vehicle Repair Costs
Notes
Save
Submit
Should be Empty: