INCIDENT NOTIFICATION FORM

(for incidents investigation level A(+) / B and C)

Form No: FORM-JBK-HSSE-INF-001

Date: 14 Feb 17 Revision No:

TO BE COMPLETED WITHIN 12HRS

Report no: Date:
1. GENERAL INFORMATION Event title:

2. PROJECT/SITE DETAILS
SUBCONTRACTOR Worksite activity (e.g.
Project (contract)
Worksite CONTRACTOR construction, installation, Job code Client Country
Name maintenance, drilling, etc)
NAME

3. EVENT DETAILS

INCIDENT Date: Hour: 1 PM

REPORTED TO Other
Discipline Supervisor Site Management HSSE
Personal injury Property/ Asset Damage Environmental Incident
ACCIDENT Outcome:

TYPE OF INCIDENT NEAR MISS Possible outcome Personal injury Property/ Asset Damage Environmental Incident

OTHER (specify):

4. INCIDENT BRIEF DESCRIPTION

INJURED PERSON

Name:

Badge no:

Role Company:

Nationality:

ATTACHMENTS

Pictures

Sketches

Other (specify):
 INCIDENT NOTIFICATION FORM
(for incidents investigation level A(+) / B and C)

Form No: FORM-TEP-HSSE-00

Date: Revision No:

5. IMMEDIATE ACTIONS TAKEN

1.

Real outcome (from Sections 1 & 2):

Incident Severity (1 to 5): 2 Inv. level for real consequence (A/B/C): A
6. Incident Classification: Incident Potentiality
and Investigation Level Potential outcome (from Sections 1 & 3):
Indicate Inv. level for potential
(the investigation level shall be chosen based on the the Potential Severity Probability
highest ranking between real outcome and potential consequence (A/B/C):
(1 to 5): 2 (1 to 5): 3
outcome) A

 Investigation level (A/B/C): A+

SECTION 2 SECTION 3: INVESTIGATION LEVEL FOR

SECTION 1: CONSEQUENCE
INVESTIGATION POTENTIAL CONSEQUENCE
LEVEL FOR
Incident Harm to Environment Damage to REAL 1. 2. 3. 4. 5.
Severity People Effect Assets CONSEQUENCES Very unlikely Unlikely Possible Likely Very Likely

Slight injury or Health

1 Slight damage
effects Negligible A A A A A B
Negligible No interruptions
(First Aid)

Minor injury or Minor damage

Local environmental
2 Health effects (Medical Short interruption
Low Treatment of Work
Restricted Case)
damage. Within the
perimeter and systems
(cost €10K-€100K, work
stopped 1 day)
A A A
A B B

Contamination
Local damage
Major injury or Health damage that effects
3 Partial shut-down
effects the environment. No B A A C
Medium (cost €100k-€500k), work B B
(Lost Time Injury) permanent effect to
stopped 1-7 days
the environment

Loss limited discharge Serious Damage

Single fatality or
4 with known toxicity. Partial service loss
Permanent Total C C C
High Affects surrounding (cost €500k-€3M) work B B B
Disability
villages stopped 2 weeks

Severe environmental Extensive damage

damage. Major Total or substantial
5
Multiple fatalities intervention required operating loss C C C C
Very High B B
for decontamination of (cost €3M-€10M), work
environment stopped over 2 weeks

7. COMMENTS

Prepared by: Signature: Date: