Notable Event Worksheet (See ES&H Manual Chapter 5200 Appendix T1 Event Investigation and Causal Analysis for Instructions)

Title of Event
Event Title:
Date and Time of Occurrence:	Notable Event Number:
Event Location:	Date Notable Event Report is Due*:

*The Notable Event Report is due to the ESH&Q Reporting Officer with 30 days of the Initial Fact Finding Meeting unless an extension is requested.

Categorization and Reporting (To be completed by ESH&Q Reporting Officer within two hours – unless essential information is still pending)
ORPS Determination:	Date:	Time:
10 CFR 851 Screen:	Date:	Time:

Unless otherwise specified the following is to be completed by the Lead Investigator.

Step 1 Initial Fact-Finding Meeting
Date:	Time:	Location:
Required Attendees:			Optional Attendees:	Ö if Present
Lead Investigator:			Associate Director:
(Print Name):			(Print Name):
ESH&Q Representative:			TJSO Observer:
(Print Name):			(Print Name):
Supervisor of involved persons(s):			Subject Matter Expert(s), Facility/Equipment Owner as applicable:
(Print Name):			(Print Name):
Involved or impacted person(s):			(Print Name):
(Print Name):			(Print Name):
(Print Name):			(Print Name):
Witness(es):			(Print Name):
(Print Name):			(Print Name):

Agenda (Ensure the pace of the meeting allows time for accurate note taking.)	Ö if Complete
1. Introduction – Provide Event Title, Date and Time of Occurrence, and Location:
2. Attendance - Are Required Attendees present.
3. Purpose of Initial Fact-Finding meeting.
4. Event Reconstruction – Use information to complete Section 3. Summary of Event and/or Injuries below.
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.
5. Clarify information – Subject-Matter Expert (SME) confirms work conditions.
6. Stop Work or the Tag Out Required? If “Yes” – establish the restart criteria and inform the affected Management chain.
7. Compensatory Actions Required? If “Yes” determine responsibility and include confirmation documentation.
8. Records or documentation required to confirm, clarify, or complete information (i.e., work plans, work control documents, photos, etc).
9. Other Questions or Concerns: Ask attendees if there are any other questions, concerns, or information that they wish to provide.
10. Obtain TJSO Observer feedback on conduct of fact finding meeting and potential improvements.

Step 2 Investigation Team:	Date Convened: (Within 24 hours of Fact Finding Meeting.)
Role	Name	Department/Group	Phone
Lead Investigator
TJSO Observer		TJSO

Step 3 Summary of Event and / or Injuries, including Initial Fact Finding Meeting information: determine the chain of events and timeline. Use attachment as necessary.

Notable Event Report

Emergency Notifications Made (Subsequent to the Event):	Date	Time
Fire, Rescue & Emergency Medical: (9-911)
Guard Post: x4444; 269-5822
Occupational Medicine 269-7539
ESH&Q Reporting Officer: 876-1750
Crew Chief 630-7050
Industrial Hygiene: 269-7863:
Other:

Witness Accounts: (Use attachments as necessary. Box will expand as necessary)

Environmental Aspects
Type of Material Released:			Quantity:
Source:			Time Flow was Halted or Controlled:
For Investigation Team (Ö All That Apply):
	Reportable Quantity	Impact Ground/Soil		Storm Water Channel/Drain	Sanitary Sewer

Records, Documents, Pictures, and Other References: (Copy and paste, use attachments or document links as necessary)

Causal Analysis: (Use attachment as necessary)

Root Cause:

Contributing Causes:

(List as many as apply.)

Extent of Condition Check	Responsible Person(s)	JLab CATS Number	Target Date

Corrective Action(s)	JLab CATS Number	Target Date

Lessons Learned (Confer with Division/Department Lessons-Learned Coordinator) (Use attachment as necessary)	JLab COE Number

Investigation Team Confirmation: The below signees, confirm to the best of their knowledge, that the information presented in this document is accurate and complete.
Role	Print Signature	Date
Lead Investigator

Upon confirmation submit document to the ES&H Reporting Officer for completion and distribution.

Documentation of Findings: (To be Completed by ESH&Q Reporting Officer)
	Notable Event Number:
	CATS Number:
	JLab COE Number:
	ORPS Number:
	NTS Number:
	CAIRS Entry:
	DOE Cause Code:
	ISM Code:

Acceptance/Acknowledgement of Facts
	Print Signature	Date:
Associate Director/ Department Manger

Distribution:

ES&H Reporting Officer (Original)

Associate Director/Department Manager

Division Safety Officer

Investigation Team Members

Form Revision Summary

Revision 1.3 – 01/31/12 – Updated ESH&Q Reporting Officer assignment from SSmith to CJohnson per MLogue

Edited to clarify process steps.

Revision 1.2 – 10/20/11 – Updated ESH&Q Reporting Officer assignment from JKelly to SSmith per MLogue.

Revision 1.1 – 05/24/11 - Edited to clarify process steps.

Revision 1 – 11/23/10 – Updated to reflect current laboratory operations.

ISSUING AUTHORITY	FORM TECHNICAL POINT-OF-CONTACT	APPROVAL DATE	EXPIRATION DATE	REV.
ESH&Q Division	Tina Johnson	10/19/09	10/09/12	1.3

This document is controlled as an on line file. It may be printed but the print copy is not a controlled document. It is the user’s responsibility to ensure that the document is the same revision as the current on line file. This copy was printed on 1/31/2012.