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Health, Safety & Environment (HSE) Rev. Issued For Reference No. Serial No. Page General Use HSE-PRO-03-F02 1 of 2
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2. Incident Classification (Insert number alongside applicable) Fatality (FAT) Lost Time Injury (LTI) Medical Treatment Case (MTC) First Aid Case (FAC) Asset Damage (AD) Road Traffic Accident (RTA) Environmental Incident Pollutant Type 3. Supervisor Detail E/N Name Phone
Restricted Work Case (RWC) Occupational Ill Health (OIH) Near Miss (NM) Quantity (liter) Present Yes/No
4. Who Informed about the Incident E/N Name Job Title Phone
5. Was an authority Involved Yes/No If yes, Authority Name : 6. Injured Person (IP) Details (provide the details of all IPs involved) S/N E/N Name of IP
Job Title
Phone
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S/N 1 2
(1) (2)
C: Company, SC: Subcontractor, TP: 3rd Party (choose as applicable) Finger, Hand, Arm, Groin, Foot, Ankle, Leg, Back, Shoulders, Torso, Neck, Head, Face, Eyes, Internal, Hip (choose as applicable)
7. Competency records (i.e. HSE Induction, other HSE Training, Toolbox Talks, 3rd Party Certifications, Training Assessments etc)
8. Asset Details (provide the details of all assets involved) S/N Code No Description Name of Operator/ driver Vessel Master Phone
1 2
S/N Owner(1) 1 C/SC/TP 2 C/SC/TP 9. Witness Details E/N Company name of SC/TP Plate No. Estimated Cost of Damage ($)
Name
Job Title
Phone
10. Circumstances (provide short description of the incident and sequence of events)
Health, Safety & Environment (HSE) Rev. Issued For Reference No. Serial No. Page General Use HSE-PRO-03-F02 2 of 2
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Choose as appropriate from the respective list provided in Appendix A of HSE-WI-003, Incident Reporting and Investigation
14. Applicable Documentation (i.e. Plans, Procedures, Work Instructions, Method Statements, PTWs, RAs, TSAs, etc.)
16. Action Plan ( all actions to be transferred to HSE-PRO-05-F03, Action Tracking and Recording Register)
17. Attachments (list as per HSE-WI-03, Incident Reporting and Investigation, Step 4.1)
18. Closed By (to be completed by the Regional HSE Manager or HSE Department Manager as applicable) Name: Incident Alert required? Completed by Job Position Name Surname Signature Date Position: YES/NO Approved by Job Position Name Surname Signature Date Date: Produced by: HSEM/RHSEM/CHSEM Distribution List Job Position Name Surname