*First Name

*Last Name

*Email

*Phone

*Area/Region

US Onshore Gulf of Mexico APA Egypt Egypt KPC New Venture North Sea Suriname

*Type of Activity

Aviation Operations Catering/Accommodation Services Completions Deck Operations Drilling Driving Facilities Engineering & Construction Field Ops Support Inspection / Survey Lifting/Rigging Work Maintenance Marine Operations Office Administration Production/Operations ROV/Diving Operations Well Services Workover

*Location

US Onshore Drilling US Onshore Completions US Onshore Workovers Facility Engineering & Construction Andrews - LEG Artesia - DB Big Lake - SMB Denver City - LEG Eunice - LEG Field Ops. Support Garden City - SMB Houston Office Midkiff - SMB Midland Office Monument – LEG Pecos - DB Snook - LEG Sundown - LEG Wildfire - SMB GOM Decom Apache Egypt KPC All All All

*Date

*Category

Idea / Suggestion Observation

*Category Subtype

*Hazard / Risk

Hazardous Substance Atmospheric / Respiratory Mechanical Electrical Pressure Temperature Biological Radiation Noise/Vibration Gravity Vehicle Excavation Environmental Safety Behaviors PPE Generic Deficiency/Hazard

*Hazard / Risk Subtype

*Life Saving Rule Category Please select at least 1 checkbox

 Confined Space
 Driving
 Energy Isolation
 Hot Work
 Line of Fire
 Safe Mechanical Lifting
 Work Authorization
 Working At Height
 NA
 Bypassing Safety Controls

*Stop Work Authority Initiated?

Yes No

*Is further action required

Yes  No