This report is required to be submitted under regulation 35(1) of the Petroleum (Environment) Regulations 2016 (the Regulations) and may be published in accordance with regulation 35A(1)(c) of the Regulations. Send the completed form to Onshoregas.DEPWS@nt.gov.au as soon as practicable and in any case no later than 15 days after the end of the reporting period, as referred to in the Onshore Petroleum Incident Reporting Guideline, or as otherwise agreed in writing with the Minister for Environment, Climate Change and Water Security.

Section 1 – Interest Holder Details
For petroleum titles held by multiple interest holders, details must be completed for each interest holder. If insufficient room, please attach information to the form.
Interest Holder 1	Interest Holder 2	Interest Holder 3	Interest Holder 4
Company Name
Nominated interest holder for all matters related to Report? If ‘no’ each interest holder must sign Declaration and will receive related documents unless designated operator authorised to sign and receive documents	☐ Yes ☐ No	☐ Yes ☐ No	☐ Yes ☐ No	☐ Yes ☐ No
Authorisation given to an Operator to submit Report and sign Declaration?	☐ Yes ☐ No	☐ Yes ☐ No	☐ Yes ☐ No	☐ Yes ☐ No

Section 2 – Recordable Incident Report Details
EMP title (petroleum title/s)	Unique EMP ID	Date Submitted	Nil report?	☐ Yes ☐ No
Activity type	Reporting Period1	Quarter:	Year:

Note 1: Refer to Table 1 of the Onshore Petroleum Incident Reporting Guideline for reporting periods and due dates.

Section 3 – Recordable Incident Details
Complete this section for each recordable incident within the reporting period, by copying the rows below and completing for each individual recordable incident.
Incident number
Incident date	Incident time	Date and time interest holder became aware
Reg 35(3)(c)(ii): All material facts and circumstances refer to Section 5.4.2 of the Onshore Petroleum Incident Reporting Guideline	Supporting information attached ☐ Yes ☐ No
Did the incident result in an environmental impact or risk not specified in approved EMP?	☐ Yes ☐ No	If yes, describe the nature and extent of the environmental impact or risk	Supporting information attached ☐ Yes ☐ No
Did the incident result in a contravention of a performance standard(s) specified in the approved EMP?	☐ Yes ☐ No	If yes, describe the contravention of the environmental performance standard(s)	Supporting information attached ☐ Yes ☐ No
Is the incident inconsistent with an environmental outcome(s) specified in the approved EMP?	☐ Yes ☐ No	If yes, describe how the incident is inconsistent with the environmental outcome(s)	Supporting information attached ☐ Yes ☐ No
If the answer to the above questions is ‘No’, consider whether the incident is a recordable incident.
Reg 35(3)(c)(iii): Action taken to avoid or mitigate any environmental impacts or risks of the incident refer to Section 5.4.3 of the Onshore Petroleum Incident Reporting Guideline	Supporting information attached ☐ Yes ☐ No
Reg 35(3)(c)(ii): Corrective action taken, or proposed, to prevent a similar incident occurring in future refer to Section 5.4.4 of the Onshore Petroleum Incident Reporting Guideline	Supporting information attached ☐ Yes ☐ No

Section 4 - Declaration
A person with legal authority to sign on behalf of the interest holder, or all interest holders (if more than one), must sign the declaration. I hereby declare that I: am authorised to make this declaration. confirm that, to the best of my knowledge all information provided addresses the relevant matters and is true, correct, complete, and does not contain misleading information am aware that it is an offence under section 107 of the Petroleum Act 1984 to give an authorised person information that I know, or ought to reasonably know, to be false or misleading in a material manner particular understand that all information supplied as part of this form, including attachments, may be disclosed publically in accordance with regulation 35A of the Petroleum (Environment) Regulations 2016, and consistent with the requirements of the Information Privacy Principles (IPPs) in the Information Act 2002.
If report being signed by interest holder/s (include attachment if more room is required to complete the below table)
Interest Holder 1	Interest Holder 2	Interest Holder 3	Interest Holder 4
Company Name
Signature
Name (print)
Position
Date
Email
If report being signed by Operator on behalf of interest holder/s
Operator details (if applicable)
Company Name	ABN/ACN
Signature	Address
Name (print)	Email
Position