Incident details Contractor name/number : (subcontractor-contractor-PDO)/CXXXXXX

1. Incident details Contractor name/number : (subcontractor-contractor-PDO)/CXXXXXX Incident owner :Name / Ref Ind Location : Area / unit - (road/yard/station/rig/hoist/plant etc) Incident date & time : (d/m/yr) / (24 hour clock) – advise if estimated Incident type : Fatal, LWC, high potential, significant incident etc Actual severity rating : Number (1-5) / letter (P, E, A,R) – from RAM Potential risk rating : Letter (A-E), Number (1-5)/letter (P, E, A,R) from RAM Description of Injuries :Worst injuries (fractures, head injury, amputation etc) FIM ID No: Number assigned in FIM Immediate cause : Short description of what caused harm Key underlying cause : Main learning from investigation

2. Description of the incident: • This should include the relevant facts explaining what happened including all relevant parties • Leading up to the incident • Immediately before the incident • During the incident • Immediately after the incident • In the emergency escalation of the incident • Important Note: • This should be in sufficient detail to allow a person who does not know anything about the incident to imagine it. It should only be about what happened and not why it happened. Do not include investigation findings here, simply describe the incident as the investigation has shown it happened. • For complex incidents involving the interaction of several different parties, a timeline can be added on a separate slide immediately after this one.

3. Declaration of close out of incident redline recommendations: The five redlined actions to prevent a reoccurrence in the future have been closed out as follows and I confirm I have seen appropriate evidence to confirm this by my signature below: Incident Owner signature: Name/Ref Ind: Date: _________________________ _______________________ ________________