Accident Number

CES ACCIDENT REPORT

To be Completed and FAXed to Manager Within 24 Hours of an Accident

Location Code Location Center District/Division Date and Time of Incident Reporting Supervisor

ACCIDENT SEVERITY ACCIDENT LOSS (may be more than one: mark all applicable)
Catastrophic Major Personal Injury Equipment Damage Vehicular Explosion / Fire
Serious Light Occupational Injury Property Damage Spill / Release Material Loss

LOCATION OF ACCIDENT (give details in the space available)

CES Base
Drilling Rig
Client Base
Public Highway
Other (specify)

PERSON(S) INVOLVED IN THE ACCIDENT

Name: Job Title: Employer: CES TPS
GPE
Name: Job Title: Employer: CES TPS
GPE
Name: Job Title: Employer: CES TPS
GPE
Name: Job Title: Employer: CES TPS
GPE

BRIEF DESCRIPTION OF THE ACCIDENT (use sketch if necessary)

BRIEF DESCRIPTION OF INJURIES OR DAMAGE

PREPARED BY:
print name signature Job Title Date

REVIEWED BY:
print name signature Job Title Date