REPORT of INJURY INCIDENT

SEVERITY: 1. 2. 3. 4. 5.
IMPACTED ELEMENT: P E A

1 2
HQ / SUBSIDIARY:
FUNCTION AND DEPT. JOB CENTER

INJURED PERSON
NAME SURNAME COMPANY EVENT LOCATION
in case of INJURY
REGISTRATION A) JOB EVENT N° in ITINERE YES NO
WAREHOUSE WORKER WIRE- LINE PERSON.- W/O
AGE ELECTRICAL MAINT. MANAGEMENT ACCIDENT DATE TIME
MECHANICAL MAINT. SUPERVISOR
HIRED in YEAR INSTRUMENTATION MAINT. TECHNICIAN ABANDONMENT DATE
LABORATORY PERSONNEL VISITOR
JOB SENIORITY OFFICE PERSON DRIVER WORK SHIFT 1 2 3 D
MARINE CREW OTHER (Specify) ACTIVITY COVERED by
PRODUCTION PERSON. WORK PERMIT / RISK ASSESSMENT YES NO

EVENT DESCRIPTION

B) EVENT LOCATION C) EVENT SITE D) ACCIDENT TYPE E) CONTINGENT EVENT

GAS / OIL PLANT WELL HEAD AREA COLLISION WITH… FALL of OBJECTS ELECTRICAL EQUIPMENT
DRILLING SITE PROCESS PLANT HIT BY… OBJ. IMPROPERLY PLACED WELDING/CUTTING
CONSTRUCTION SITE TANK AREA CRUSHED BY… HAND TOOLS ADVERSE WEATHER
PRODUCTION PTF. RIG FLOOR RUN OVER BY ... MATERIALS HANDLING WHEELS, DRILLS, LATHES
DRILLING PTF. YARD CUT INSTRUMENT MAINTEN. VEHICLES/EQUIPMENT
PTF. IN CONSTRUCTION WORKSHOP EXCESSIVE PHISICAL STRAIN DESCEND from VEHICLES WORKING SURFACE/FLOOR
MAIN OFFICE INSTRUMENTAL/CHEM. LAB. FLAT FALL OPERATIONS in ELEVAT. ROAD ACCIDENT
ROAD ELET: CAB/CONTROL ROOM FALL FROM HEIGHT STAIRS & SCAFFOLDING ROAD CONDITIONS
WELL WAREHOUSE SLIPPED / TRIPPED TRANSFERRING FLUIDS OTHER (Specify)
SUPPLY BASE KITCHEN/QUARTERS INHAL, INGEST, ABSORB. TRANSFERRING PEOPLE
OTHER (Specify) OFFICE CONTACT DANGEROUS SUBST.
OWN VEHICLE CONTACT H/L TEMP. F) INCIDENT TYPE
COMPANY VEHICLE ELECTROCUTION FIRE PLANE CRASH
G) TREATMENT SITE PIER ON BOARD / DRIVING... EXPLOSION NAVAL ACCIDENT
THIRD PARTY VEHICLE OTHER (Specify) TOXIC SUBSTANCES RELEASE TRIPS/SLIPS AND FALLS
COMPANY SURGERY OTHER (Specify) STRUCTURES COLLAPSE OTHER (Specify)
EXTERN. MEDICAL SURG. SPILL/DISCHARGED OTHER (Specify)
HOSPITAL

H) INJURIES LOCATION I) INJURIES TYPE

HEAD HAND/WRIST/FINGER RESPIRATORY SYSTEM WOUNDS INJURIES from FOREIGN BODIES/SUBST.
FACE BACK/SPINAL COL. CARDIO VASC. SYSTEM ABRASIONS INJURIES from HEAT/COLD
EYE ARM/SHOULDER DIGESTIVE SYSTEM BRIUSES and CRUSHING INTOXICATION
EAR FOOT/ANKLE MULTIPLE HEAD/LIMBS DISLOCATION, SPRAIN, STRAIN AMPUTATION
NOSE CHEST REGION MULTIPLE HEAD/CHEST BACKLASH ELECTROCUTION
MOUTH LUMBAR-SACRAL REGION MULTIPLE CHEST/LIMBS FRACTURE / INFRACTION IONIZING RADIATION
NECK ABDOMINAL REGION MULTIPLE UPP/LOW LIMBS CONCUSSION/ INTERNAL TRAUMA SUFFOCATION / DROWNING
LEG GROIN OTHER (Specify) STRAIN INJURY MEDICAL TREATMENT CASE
MULTIPLE INJURIES OTHER (Specify)
FATAL ACCIDENT CASE

REMARKS

WITNESSES WORKING TEAM / Signature /

OCCASIONAL / Signature /

INJURED PERSON Signature (if possible) REPORT COMPILER SUPERVISOR

DIAGNOSIS FIRST PROGNOSIS 3

DEPARTMENT MANAGER Signature

HSE REPRESENTATIVE Signature

SUBSIDIARY GEN. MANAGER Signature

REPORT COMPILATION DATE

MOG-HSEQ-F-085 Rev A4 Accident/Incident