TITLE:	ES&H Manual
DOCUMENT ID:	5200 Appendix T2 Notable Event Worksheet

Unless otherwise specified, this form is to be completed by the Lead Investigator.
Subject:
Date and Time of Occurrence:
Location:
To be Completed by ESH&Q Reporting Officer:
	Notable Event Number:
	CATS Number:
	OccMed Number:
	JLab COE Number:
	ORPS Number:
	Environment Report:
	NTS Number:
	CAIRS Entry:
	DOE Cause Code:
	ISM Code:
1. Team Members
Name		Dept			Phone
		Lead Investigator			X
TJSO Observer Name:		TJSO Critique Member			X
					X
					X
					X
					X
					X
2. Summary of Event and / or Injuries, including Critique information:
3. Witness Accounts:
4. Causal Analysis:
Root Cause:
Contributing Causes: (List as many as apply)
5. Extent of Condition Check		Responsible Person(s)			Target Date
6. Corrective Action(s)		JLab CATS Number			Target Date
7. Lessons Learned:				JLab COE Number
8. Lead Investigator's Release of Document
Document Complete?			YES NO

Critique Meeting:
Required Attendees:	Present? Y or N	Optional Attendees:	Present? Y or N
Lead Investigator:		Associate Director:
ESH&Q Representative:		Subject Matter Expert(s):
Supervisor of involved persons(s):		TJSO Representative:
Involved or impacted person(s):		Facility or Equipment Owner, if applicable:
Witnesses:
	\
Initial Critique Meeting Checklist: (Ensure the pace of the critique allows time for accurate note taking.)			Complete? Y or N
1. Appropriate records or documentation are available for viewing (work plans, photos, etc).
2. Required personnel are present per ESH&Q Manual Chapter 5200-T1, 4b.
3. Introduction
4. Review purpose of Initial Critique meeting.
5. Event Reconstruction, including chain of events and timeline.
a. If required develop compensatory actions and ensure their implementation.
6. Does the situation warrant a Stop Work or the tag out of equipment? .
a. If “Yes” – establish the restart criteria and inform the affected Management chain.
7. Personnel Input: provide an opportunity for involved, impacted and witnesses to tell what happened. Include:
a. Personnel and organizations involved in the event;
b. Conditions and actions preceding the event;
c. Chronology (timeline) of the event; and
d. Immediate actions taken in response to the event.
8. Subject-Matter Expert (SME) – clarify information.
9. Determine missing information (i.e., Work Control Documents, Planning Material, etc)
10. Ask attendees if there are any other questions, concerns, or information that participants wish to provide.
11. Obtain DOE feedback on conduct of critique and potential improvements.

Notifications:
	Date			Time
GUARD STATION: x4444:
CHEMICAL ASSIST TEAM: x7863:
AMBULANCE: (9-911)
CREW CHIEF (630-7050)
ESH&Q REPORTING: x7007:
FIRE: (9-911)
OTHER:
OTHER:
Environmental Conditions:
TYPE OF MATERIAL:		QUANTITY:
SOURCE:		TIME FLOW WAS HALTED OR CONTAINED:
For Investigation Team (X All That Apply):
Reportable Quantity?	Impact Ground/Soil?		Storm Channel/Drain?		Sanitary Sewer?

To be completed by ESH&Q Reporting Officer:

ORPS Determination:

10 CFR 851 Screen:

	Pictures and References
Distribution:		ESH&Q Reporting Officer (Original) Division Safety Officer Investigation Team Members