Please enable JavaScript in your browser to complete this form.1Company Information2Environmental Data3Leading Indicators4Lagging Indicators5IncidentsCompany InformationYear *Contact Name *Contact Phone Number *Contact Email Address *Job Title *Company DataWorking Hours - Based on 12-hour workdayLand EmployeeLand ContractorMarine EmployeeMarine ContractorNumber of High Potential IncidentsLand EmployeeLand ContractorMarine Employee Marine ContractorNextEnvironmental DataTreated Grey and Black Water (Liters)Land TotalMarine TotalWaste Recycled or Treated (lbs)Land TotalMarine TotalHydrocarbon Spills (Total Reportable Spills)Land Total Marine TotalGhost Net Initiative - Total Debris Recovered (Estimated Tons)Marine TotalGhost Net Initiative - Estimated Cost for Debris RemovalMarine TotalPreviousNextLeading IndicatorsBBOs (Behavior Based Observations)Land TotalWater TotalToolbox MeetingsLand Total Water TotalOrientations / IntroductionsLand Total Water TotalCross InspectionsLand TotalWater TotalEmergency Response DrillsLand TotalWater TotalJob Safety Anaylsis / Task Hazards AnalysisLand TotalWater TotalManagement System AuditsLand Total Water TotalTraining HoursLand TotalWater TotalPermit to WorkLand TotalWater TotalManagement of ChangeLand TotalWater TotalPreviousNextLagging Indicators - LandNumber of FatalitiesEmployee InjuryEmployee IllnessContractor InjuryContractor IllnessThird PartyPermanent Total DisabilityEmployee Injury Employee Illness Contractor InjuryContractor IllnessPermanent Partial DisabilityEmployee Injury Employee Illness Contractor InjuryContractor IllnessNumber of Lost Workday CasesEmployee Injury Employee Illness Contractor InjuryContractor Illness Third PartyNumber of Restricted Workday CasesEmployee InjuryEmployee IllnessContractor InjuryContractor IllnessNumber of Medical Treatment CasesEmployee InjuryEmployee IllnessContractor InjuryContractor IllnessNear MissesEmployee Injury Contractor Injury Motor Vehicle IncidentsEmployee InjuryEmployee IllnessKM / Miles Driven (Please use appropriate box)Lagging Indicators - MarineNumber of FatalitiesEmployee IllnessEmployee InjuryContractor IllnessContractor InjuryThird PartyPermanent Total DisabilityEmployee Illness Employee Injury Contractor IllnessContractor InjuryPermanent Partial DisabilityEmployee IllnessEmployee InjuryContractor IllnessContractor InjuryNumber of Lost Workday CasesEmployee IllnessEmployee InjuryContractor InjuryContractor IllnessThird PartyNumber of Restricted Workday CasesEmployee IllnessEmployee Injury Contractor IllnessContractor InjuryNumber of Medical Treatment CasesEmployee IllnessEmployee InjuryContractor IllnessContractor InjuryFirst Aid CasesEmployee Illness Employee Injury Contractor IllnessContractor InjuryNear MissesEmployee IllnessEmployee InjuryContractor IllnessContractor InjuryPreviousNextIncident 1Incident TypeRecordableRecordableFirst AidOperationLandLandMarinePersonnelEmployeeEmployeeContractorJob TypeCatering / UtilityCatering / UtilityClientCommunicationDrillerDrivers Inc.VibsLaborersLine CuttersLinesmenMechanicsObserversParty Chiefs / APCPilot / AviatorPowder ManProcessingSafety - HSE / MedicsSurveyorsTechnicaisnOtherUnknownWork AreaCrew in TransitCrew in TransitDrilling Operations - LandDrilling Operations - MarineExplosivesHandling HazMat (MSDS)PermittingLine Clearance / ReclamationSeismic - Layout & PickupSeismic - Record/ShootSurface Energy SoiurcesVehiclesSmall Boat OperationsHelicopter OperationsOther OperationsNot KnownCategoryAssault or Violent ActAssault or Violent ActCaught in, Under or BetweenConfined SpaceChoice 12Choice 11Choice 10Choice 9Choice 8Choice 7Choice 6Choice 5Choice 4Body PartAnkle / FootAnkle / FootBackTorso / Main BodyEyeRespiratory SystemCardiovascular SystemNeurological SystemDigestive SystemUrinary / Genital SystemOtherNot KnownIncident 2Incident TypeRecordableRecordableFirst AidOperationLandLandMarinePersonnelEmployeeEmployeeContractorJob TypeCatering / UtilityCatering / UtilityClientCommunicationDrillerDrivers Inc.VibsLaborersLine CuttersLinesmenMechanicsObserversParty Chiefs / APCPilot / AviatorPowder ManProcessingSafety - HSE / MedicsSurveyorsTechnicaisnOtherUnknownWork AreaCrew in TransitCrew in TransitDrilling Operations - LandDrilling Operations - MarineExplosivesHandling HazMat (MSDS)PermittingLine Clearance / ReclamationSeismic - Layout & PickupSeismic - Record/ShootSurface Energy SoiurcesVehiclesSmall Boat OperationsHelicopter OperationsOther OperationsNot KnownCategoryAssault or Violent ActAssault or Violent ActCaught in, Under or BetweenConfined SpaceChoice 12Choice 11Choice 10Choice 9Choice 8Choice 7Choice 6Choice 5Choice 4Body PartAnkle / FootAnkle / FootBackTorso / Main BodyEyeRespiratory SystemCardiovascular SystemNeurological SystemDigestive SystemUrinary / Genital SystemOtherNot KnownIncident 3Incident TypeRecordableRecordableFirst AidOperationLandLandMarinePersonnelEmployeeEmployeeContractorJob TypeCatering / UtilityCatering / UtilityClientCommunicationDrillerDrivers Inc.VibsLaborersLine CuttersLinesmenMechanicsObserversParty Chiefs / APCPilot / AviatorPowder ManProcessingSafety - HSE / MedicsSurveyorsTechnicaisnOtherUnknownWork AreaCrew in TransitCrew in TransitDrilling Operations - LandDrilling Operations - MarineExplosivesHandling HazMat (MSDS)PermittingLine Clearance / ReclamationSeismic - Layout & PickupSeismic - Record/ShootSurface Energy SoiurcesVehiclesSmall Boat OperationsHelicopter OperationsOther OperationsNot KnownCategory Assault or Violent ActAssault or Violent ActCaught in, Under or BetweenConfined SpaceChoice 12Choice 11Choice 10Choice 9Choice 8Choice 7Choice 6Choice 5Choice 4Body Part Ankle / FootAnkle / FootBackTorso / Main BodyEyeRespiratory SystemCardiovascular SystemNeurological SystemDigestive SystemUrinary / Genital SystemOtherNot KnownBody Part (copy)Ankle / FootAnkle / FootBackTorso / Main BodyEyeRespiratory SystemCardiovascular SystemNeurological SystemDigestive SystemUrinary / Genital SystemOtherNot KnownIncident 4Incident Type RecordableRecordableFirst AidOperation LandLandMarinePersonnel EmployeeEmployeeContractorJob Type Catering / UtilityCatering / UtilityClientCommunicationDrillerDrivers Inc.VibsLaborersLine CuttersLinesmenMechanicsObserversParty Chiefs / APCPilot / AviatorPowder ManProcessingSafety - HSE / MedicsSurveyorsTechnicaisnOtherUnknownWork AreaCrew in TransitCrew in TransitDrilling Operations - LandDrilling Operations - MarineExplosivesHandling HazMat (MSDS)PermittingLine Clearance / ReclamationSeismic - Layout & PickupSeismic - Record/ShootSurface Energy SoiurcesVehiclesSmall Boat OperationsHelicopter OperationsOther OperationsNot KnownCategory Assault or Violent ActAssault or Violent ActCaught in, Under or BetweenConfined SpaceChoice 12Choice 11Choice 10Choice 9Choice 8Choice 7Choice 6Choice 5Choice 4Body Part Ankle / FootAnkle / FootBackTorso / Main BodyEyeRespiratory SystemCardiovascular SystemNeurological SystemDigestive SystemUrinary / Genital SystemOtherNot KnownIncident 5Incident 6Incident 7Incident 8Incident 9Incident 10Incidents Form Click or drag a file to this area to upload. 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