Accident Reporting Form

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NIGERIAN MIDSTREAM & DOWNSTREAM PETROLEUM REGULATORY
AUTHORITY (NMDPRA)
ACCIDENT REPORTING FORM FOR MIDSTREAM & DOWNSTREAM PETROLEUM INDUSTRY

1.
Name and address of operating company:
______________________________________________________________________________________
2.
Name of employee / contractor / third party involved in the accident, if any:
______________________________________________________________________________________
3. Occupation of the victims: ________________________________________________________________
4. Date and time of accident: Date_________________20_______ Time: ____________________
5. (A) Nature of accident: Fatal: Non-fatal:
(B) Total accident recorded year to date in your operations: ____________________________________
6. Location of facility where the accident occurred:
a. LGA:
b. State:
c. Geo Coordinates:
d. OPL/OML (If applicable):
7.
(A) Number of fatalities, including their names: _____________________________________________
_____________________________________________________________________________________
(B) Number of injured persons, including their names: _______________________________________
_____________________________________________________________________________________
8. Equipment and material damaged: ________________________________________________________
9. Probable cause of the accident:
_____________________________________________________________________________________
10. Date and time of application of first aid: Date: ___________________ Time: __________________
11. Date injured persons was sent to the hospital: Date: _________________________________________
12. Place where injured persons may be interviewed: ____________________________________________
13. Please state in your opinion if the accident was due to the serious and willful misconduct of the injured
people or others working with them or caused by faulty equipment:
________________________________________________________________________________________
14. Preventive / control measures (emergency response activities, actions taken to save lives, equipment and
or prevent reoccurrence)
________________________________________________________________________________________
15. Do you wish to attend or to be represented at any inquiry under regulations 45? Yes _________________
16. Names and Addresses of Witnesses present:
________________________________________________________________________________________

_______________________________________ Date:_________________________________
Sign; MD / HSE Manager / Operations Manager

Note:
All accidents in Midstream & Downstream facilities/operations must be reported to the nearest NMDPRA
office and the Authority Chief Executive within 24 hours and 48 hours respectively, as stipulated in Part II
Section 44 (2) of the MOSR 1997, and also send a copy of the filled form to HSEC@nmdpra.gov.ng
FORM HSEC 01