Initial Incident Report by X7uYuEq

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									Fill this form out and email to the appropriate safety rep:

Phase II - Spread 9: Brad.willey@exp.com
Phase II - Spread 10: Brad.willey@exp.com
Phase II - Spread 11: Brad.willey@exp.com
Gulf Coast Project - Holdenville Office - Spread 1: Dwight.shipman@exp.com
Gulf Coast Project - Tyler Office - Spread 2: Dwight.shipman@exp.com
Gulf Coast Project - Sourlake Office - Spread 3: Fred3.trainer@yahoo.com
Gulf Coast Project - Houston Office: Brad.willey@exp.com
Houston Lateral: Brad.willey@exp.com
Keystone XL Segment - Norfolk, Nebraska Office: Tony.baranowski@exp.com
Keystone XL Segment - Rapid City, South Dakota Office: Tony.baranowski@exp.com
Keystone XL Segment - Miles City, Montana Office: Tony.baranowski@exp.com
Keystone XL Segment - Houston Office: Tony.baranowski@exp.com

KEYSTONE PIPELINE PROJECT
INITIAL INCIDENT NOTIFICATION
Figure 8-5
Revised May 13, 2010

1. HEADER
Incident Number:       (office use)
Accountable Organization Unit:
Overall Accountable Person:
Operating Entity: Keystone Oil Pipeline Project
Date of Incident:
Time of Incident:
Date Incident Reported:
Reported By:
State:
County:
Primary Field Office:
Mile Post (If applicable):
Tract Number (If applicable):
Location Type/Facility:
Type of Activity (Crew Type) Land Survey, Cultural, etc:
Company Name:

Choose the Appropriate Designation (Delete those that are not applicable)
Near Hit
Observation
24x7 Safety (Incident not work related)

2. CLASSIFICATION (delete all that are not applicable)
Vehicle Incident
Personal Injury or Illness
Activation of Safety Device,
Complaints
Fire/Explosion
Non-compliance
Power line or Cable Contact
Miscellaneous (specify)
Security

3. DESCRIPTION OF INCIDENT

Incident Summary (No names to be entered in this field):

ADDITIONAL INFORMATION:

Identify Immediate and Root Cause:

Action taken to prevent recurrence (List any Action Items):

Damage to Company or Third Party Property:

Nature and Extent of Environmental Concerns:

4. FATALITY or INJURY / ILLNESS DESCRIPTION
(If a fatality has occurred, complete the information only after next of kin have been notified)

Employee Name:

Employer Name:

Description of injury/illness:

5. NAME OF AGENCIES OR AUTHORITIES NOTIFIED (List all) (Police/Fire/Ambulance/Regulatory)

Agency (s)
Contact Name:
Contact Information:
Date:
Time:
6. CLASSIFICATION: (for office use only)
Actual Severity (delete all that do not apply) (Delete all for Near hit)
Minor Incident
Serious Incident
Major Incident
Critical Incident

Potential Severity
Minor Incident
Serious Incident
Major Incident
Critical Incident
Further investigation required Y/N

7. REPORTING AND TIMING

Employee Supervisor (Name, Phone Number)
Time report received:

Time/Date report received By Chief or Safety Representative:

								
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