ST00.653.F1115 – R1.

HSE Incident Communication

Basic Facts
Project/Office/Country

Date and Time of Incident Date: Time:

Location Where Incident Occurred

Occupation of Involved Person(s)

Environmental Equipment/Property Damage Fire

Type of Incident
Injury/Illness Motor Vehicle Accident Near Miss
Description of any Injury

Initial Injury Classification

0 1 2 3 4
Actual Severity

Potential Severity

Brief Description of Incident, Injury, Substantial Property Damage, and/or Environmental Damage
(keep information factual with no speculation)