Report of an Oil and Gas Incident (rogi) Form Interim version Guidance Who should use this form?



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53.Part J Detailed Report


Major environmental Incident arising from a Safety Incident. (Note: PON1 reporting is still a requirement. The ROGI form is additional in the event of a Major environmental incident)
Implementing Regulation Section J: A Major Environmental Incident

54.Section J1





General information

Name of contractor (if applicable)

Enter name of contractor



55.Section J2





Description of circumstances, consequences of event and emergency response

Indicate the system that failed and provide a description of the circumstances of the event / describe what has happened. What are or are likely to be the significant adverse effects on the environment?

Enter description



56.Section J3





Preliminary direct and underlying causes (within 10 working days of the event)

Enter causes



57.Section J4





Initial lessons learned and preliminary recommendations to prevent recurrence of similar events (within 10 working days of the event)

Enter lessons learned and recommendations


End of Part J Detailed Report

58.Part K Detailed Report


Other reportable injuries, Diseases and Dangerous Occurrences: (Over Seven day injuries, Occupational Diseases; Exposure to Carcinogens, Mutagens and Biological Agents: Diseases Offshore; Diving Operations; Dropped Objects; Fall into Water; Lifting equipment; Biological agents; Radiation; Breathing Apparatus; Pipelines or Pipeline Works)
RIDDOR 2013 4(2) Over-Seven-Day Injuries to Workers/8. & Schedule 1 Part 1 2.(1)Occupational Diseases/9. Exposure to Carcinogens, Mutagens and Biological Agents/10. & Schedule 1 Part 1 2.(1) Diseases Offshore/ Diving Operations Schedule 2 13-17

Dangerous Occurrence Form: RIDDOR Schedule 2 Part 6 80. Dropped Objects/ 87. Fall into Water



59.Accident Report





About the kind of accident

Select the kind of accident that best describes the incident

Choose kind of accident

If a fall from height- how high was the fall (to the nearest meter)

Enter measurement

Work process involved in the incident

Choose a work process

Main factor involved in the incident

Choose a main factor

Describe what happened

(give as much detail as you can, including i) the events that led to the incident ii) the operation or activity in progress. Describe any action taken to prevent similar incidents occurring.)

Enter description




About the Injured person

Name

Family name

Address Line 1

Enter address line1

Address Line 2

Enter address line 2

Address Line 3

Enter address line 3

Town

Enter Town

County

Enter county

Post Code

Enter postcode

Phone No

Enter phone number

Gender



Male



Female




Age

Enter age




Injured person’s employment status

Was the injured person



One of your employees?



On a training scheme?






Employed by someone else?



On work experience?






Self-employed and at work?



Member of the public?

Details if the person was on a training scheme / employed by someone else

Enter details




About the severity of the person’s injuries

Please refer to the help for guidance on severity of injury



Please help us determine the severity of the injury

Was the injury fatal



Yes



No




If no, was the worker’s injury one of these (as specified under RIDDOR):


  • bone fracture excluding finger, thumb or toe

  • amputation of arm, hand, finger, thumb, leg, foot or toe

  • blinding or permanent sight reduction

  • crush injuries leading to brain damage or internal organ damage

  • serious burns

  • scalping requiring hospital treatment

  • loss of consciousness caused by head injury or asphyxia

  • injuries associated with working in an enclosed space leading to hypothermia or heat-induced illness, resuscitation, hospitalisation for over 24 hours






Yes



No










If no, the injury prevented the worker from carrying out their routine work for more than 7 days












Yes










The injury was to a member of the public taken directly to hospital / injured on hospital premises












Yes

About the person’s injuries

Injuries

Choose an injury

Parts of the body Affected

Choose the part of the body affected



60.Dangerous Occurrence Report





Type of dangerous occurrence

Choose an occurrence

Describe what happened




Enter description


61.Occupational Disease Report





Affected person’s name

Enter name

Gender



Male



Female

Age

Enter age




What was the person’s occupation or job title

Enter occupation or job title

Work Status

Enter work status

Date the disease was diagnosed / confirmed

Enter date

Where was the disease contracted?

Enter location

Disease category diagnosed

Choose a disease category

Specify the diagnosed disease

Enter disease

Details of the work activity that led to the disease

Enter work related cause


End of Part K Detailed Report

62.Part L Detailed Report


Death or Loss of a Person Pursuant to MAR Regulation 21B (Note: although provided within the ROGI Form this must be printed and sent to the Registrar General of Shipping and Seamen)
Form to be Completed in respect of the death or loss of a person pursuant to Regulation 21B – Offshore Installations and Pipelines Works (Management and Administration) Regulations 1995


Section L only is to be printed out and the form is to be sent to the :




Registrar General of Shipping and Seamen

Anchor Court

Keen Road

Cardiff


CF24 5JW




PART 1

Name or other designation of offshore installation

Enter name of offshore installation

Date of death or loss

Enter date

Place of death or loss(a)

Enter location

Full name of deceased or person lost(b)

Enter name

Gender



Male



Female

Age

Enter age

Capacity in which person deceased or lost was engaged or other reason for presence at the installation

Enter details

Cause of death or loss(c)

Enter cause




I certify that the particulars entered above are true to the best of my knowledge and belief:

Signature of installation manager furnishing information


Name of installation manager furnishing information(b)

Enter name

Status of signatory

Enter status

Date of signing

Enter date




PART 2(d)

Date of birth

Enter date in format dd/mm/yyyy

Usual place of residence

Enter location

Nationality of deceased or person lost

Enter nationality

Name and address of next-of-kin

Enter name
Enter address

Relationship of next-of-kin

Enter relationship




I certify that the particulars entered above are true to the best of my knowledge and belief:

Signature of duty holder furnishing information or person acting on behalf of duty holder



Name of duty holder/pm whose behalf information is furnished

Enter duty holder name

Status of signatory

Enter status

Date of signing

Enter date

NOTES
(a) To be given by geographical co-ordinates.
(b) Forename(s) in full, followed by surname, all in block capitals.

(c) To be accompanied by the certificate of a registered medical practitioner who holds a licence to practise as to the cause of death or a statement of the reason why such a certificate is not available.



End of Part L Detailed Report

ROGI Form 1.4 - Date of Issue 03/02/2016

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