Ace Energy Services Safety & Quality Portal

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Job Setup:Set once. Attaches to every form you submit.

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🚨 Incident Report

Ace Energy Services Safety Management System

📋 Basic Information

Incident Date *

Incident Time

Rig *

👤 Reporter Information

Your Name *

Email *

Phone

📝 Incident Description

Incident Type(s) *(Select all that apply)

Injury - Classification PendingIllness - Classification PendingNear Miss / Close CallFirst Aid OnlyProperty / Equipment DamageVehicle IncidentSpill / ReleaseEnvironmental ImpactFireExplosionProcess Safety Event (LOPC)Security IncidentOther

Brief Description *

Detailed Description

⚠️ Severity Assessment

Was there an injury or illness? *

YesNo

Safety Severity - ACTUAL Outcome *

A - Fatality

Fatality or potential for >25 fatalities

B - Permanent Total Disability

Permanent total disability or potential for 10-25 fatalities

C - Serious Injury

Serious injury (hospitalization) or potential for 3-9 fatalities

D - Lost Time Injury

Lost workday case or potential for 1-2 fatalities

E - Medical Treatment

Medical treatment or permanent partial disability potential

F - First Aid / Minor

First aid or single/multiple recordable potential

G - Near Miss / No Injury

Near miss or first aid/exposure potential

Safety Severity - POTENTIAL Outcome (What could have happened?)

⚡ STKY / SIF Potential Assessment

STKY = Stuff That Kills You
This assessment identifies whether high-energy sources were present that could result in Serious Injury or Fatality (SIF).

Was HIGH ENERGY present? *

YesNo

🔍 Initial Investigation

Immediate Actions Taken

Witness Information (if any)

Suspected Root Causes (Initial Assessment)

Initial Lessons Learned

📷 Photo Documentation

Photos (Recommended)

📷

Tap to take or upload photos

Photos help document the incident scene and conditions

AnthroSafe™ Field Driven Safety

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