Incident/Injury Investigation Report
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Employee Name: *
Date of Incident *
MM
/
DD
/
YYYY
Time of Incident: *
Time
:
Location of Incident (Co. Name, Street Address, City, State, Lease Name, Well #):  *
Equipment #: *
List of Names of Other Workers On-Site at Time of Incident: *
Is the incident bodily injury, damaged equipment, or both? *
List Name(s) of Injured: (If there was a injury)
List Any Equipment Damage. (Be Specific):
Describe the Nature and Extent of Injuries (Be Specific):
Was the Injured Offered Medical Treatment?  (If there was injury) *
Did the Injured Get Medical Treatment?   (If there was injury) *
Name of Medical Facility:  (If there was treatment)
Did Injured Refuse Medical Treatment? (If yes, Injured Must Sign Refusal of Medical Treatment Form) *
Describe the incident: 
Who was involved?  
When did the incident occur?  
Where? 
What Was the Employee(s) Doing? 
How and why did the incident occur?  (Be Specific):
How was the incident resolved? (If not resolved, explain what the next step is to resolve the issue.)

 *
List any improvements or corrective actions needed to prevent the reoccurrence of this incident: (Be specific, i.e. Equipment Additions, Process Improvements, Additional Training, etc...) *
Are there Witness Statements, photos, diagrams or any other information available related to this incident? *
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