Incident Notification
Type of Notification
*
First Notification of Incident
In Progress
Final Report
Information Only
Non-Work Related
Type of Incident
*
Injury
Damage
Vehicle
Fire
Near Miss
Reputation
Illness
Nature of Injury
Laceration
Bruise
Burn
Amputation
Sprain/Strain
Exposure
Fracture
Poison
Open Wound
Dislocation
Foreign Body
Nerve Damage
Spinal Injury
Head Injury
Internal Injury
(HSE Use Only)
Type of Injury
First Aid
Recordable
Lost Time
Information Only
(HSE Use Only)
AXIOM Notified
Post Incident Drug/Alcohol Screen
Division Where Incident Occurred (Choose all that apply)
*
JMAC
WDW
IHD Liquids
IHD Solids
Construction
Trucking
Shop
Materials
Ft. Berthold
South Texas
West Texas
New Mexico
Bismark
Idaho
Oregon
Washington
Williston
Not Work Related
Other
Location of Injury
Eye
Nose
Mouth
Teeth
Ear
Cheek
Chin
Forehead
Top of Head
Back of Head
Shoulder
Upper Arm
Elbow
Fore Arm
Hand
Finger(s)
Thumb
Palm
Thigh
Knee
Shin
Calf
Ankle
Foot
Toe(s)
Collar Bone
Ribs
Sternum
Internal Organs
Lower Abdomen
Kips
Groin
Neck
Upper Back
Middle Back
Lower Back
Spine
Other
(HSE Use Only)
Mechanism of Injury
Fall From Height
Fall at Same Level
Slip/Trip
Repetitive Motion
Exposure to Heat/Cold
Vibration
Contact Moving Part
Muscular Stress
Contact Chemical
Noise Exposure
Mental Stress
Struck Object Body
Electrical Contact
Radiation Exposure
Hit By Object
Vehicle Accident
Bites/Stings
Internal Injury
Other
(HSE Use Only)
Date of Incident
*
Time of Incident
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
05
10
15
20
25
30
35
40
45
50
55
Minutes
AM
PM
AM/PM Option
Date Reported
*
Time Reported
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
05
10
15
20
25
30
35
40
45
50
55
Minutes
AM
PM
AM/PM Option
Injured Person/Driver(s)
*
Person Reporting Name
*
First Name
Last Name
Person Reporting Email Address
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Location of Incident (Required)
Rig Name, Pad Name, Highway Name, Intersection, Project, Office etc...
Client Name
When Incident Occurred Involving Client Project Include Client Name
Subcontractor/Lessee/Customer Company Name
Subcontractor, Lessee or Customer Involved - Include Company Name
Gender
Male
Female
Marital Status
Single
Married
Position/Title
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
For Injuries Beyond First Aid
Date of Hire
-
Month
-
Day
Year
Date
Years of Industry Experience
Years In Current Position
Supervisor
First Name
Last Name
Witness/s (Click [Save] to add additional witness/s)
What Happened?
Upload Witness Statements
Browse Files
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of
Upload Drug & Alcohol Test Verification
Browse Files
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of
Upload Incident Report
Browse Files
Cancel
of
Capture/Upload Photo(s)
Browse Files
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of
(Other) File Upload
Browse Files
Cancel
of
Investigation
HSE DEPARTMENT USE ONLY
Clinic/Hospital
Name
Physician/Dr
Clinic/Hospital
-
Area Code
Phone Number
Clinic/Hospital
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Investigation Leader
First Name
Last Name
Title
Investigation Team
Causal Chart
Rows
Contributing Events
Contributing Factors
Causal Factors
Root Cause
Action 1
Action 2
Action 3
Action 4
Action 5
Action 6
Action 7
Action 8
Action 9
Action 10
Root Cause(s)
System Factors
Rows
In Place
Somewhat Satisfied
People:
(check training records and competency, review previous incidents)
(following instruction, fitness for work, attitude, complacency, inexperienced, rushing, risk assessment conducted prior to commencing task)
Environment
(check surroundings, access, egress, hostile environment, work space, housekeeping, noise, dust, confined areas, weather, poor visibility, task unfamiliarity, uneven ground, wildlife)
Equipment and Materials
(check chemicals, tooling and equipment)
(check suitability, fit for purpose, approved for site use, design, modifications, suitability, condition, guarding, maintenance records)
Methods of Work
(check procedures, permits, training, instructions, Take 5, Job Hazard Analysis, risk assessments, licences)
Organization
(check systems of work, training provided, supervision, communications, instructions given, personal protective equipment provided, culture, pressures)
Corrective Action Item(s)
Submit
Should be Empty: