N-03000-FM0522 - Monthly Summary Report

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					                                                                                                                  Due Date: By the 15th day of the following month.
                    Deaths or Injuries - Monthly Summary Report                                              Send completed form to: submissions@nopsema.gov.au



     Operator:                                          Month:                                                                    Year:
 Contact Person:                                        Email:                                                                    Phone:
                                                   Employees/                             Number of Incidents: Each injury must be assigned to one category only
                                                   Contractors/
                                  Type of                                                                    Lost Time Injuries    Lost Time Injuries   Medical Treatment    Alternative
              Facility Name                                               Fatalities        Major Injuries
                                  Facility         Marine Crew                                               of 3 or more days       of 1 or 2 days          Injury         Duties Injury
                                                                             FT                  MI
                                                    TOTAL HRS                                                     LTI ≥3                LTI <3                MTI               ADI




Revision: 3                                                                 Page 1 of 2                                                                    Reference: N-03000-FM0522
Revision Date: 08 February 2012                                                                                                                                     Objective ID: A52141
                                             National Offshore Petroleum Safety and Environmental Management Authority
                                                                                             Deaths or Injuries – Monthly Summary Report


                                                                    Operator’s                                                                                          Total Number
  Date                                  Injury          NOPSEMA       Incident      Brief Description of each Injury included in the above table.      Total Number
                                       Category                                                                                                                          Alternative
   of              Facility Name                         Incident   Number or                                                                           Work Days
                                                                                                                                                                         Duties Days
 Injury                                 Code             Number      Identifier         State clearly if the injury is due to contracting a disease.   Lost (MI, LTI)
                                                                                                                                                                            (ADI)
                                       (LTI,MTI,ADI)
                                                                        Code




Note that under the Western Australian Petroleum (Submerged Lands) Act 1982, monthly reports should be supplied to the relevant State Minister through the WA
Department of Mines and Petroleum (www.dmp.wa.gov.au) rather than NOPSEMA.




 Revision: 2                                                                          Page 2 of 2                                                      Reference: N-03000-FM0522
 Revision Date: 27 January 2012                                                                                                                                Objective ID: A52141
                                                       National Offshore Petroleum Safety and Environmental Management Authority

				
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