Electrical Shock Incident Report

• Date / Time :

  Date

Job number

• Housing Authorities Work Order Number

• Address:
  Address

• Name of person suffering Electrical Shock:

• Has the person been advised to seek appropriate medical attention:

  Yes

  No

  N/A

• Brief description of how shock occurred:

• Faults or defects identified: ( Refer also to attached test results sheet.)

• Brief description of remedial action taken:

• Further works required:

• Western Power notified of incident:

  Yes

  No

  N/A

• Ref no:

• Tradesman Name:

  Sign

• EW:

• Contact Name:

  Sign

• Address:
  Address

Test Results :

• Supply Voltage at Switchboard :

• M.E.N Link Confirmed

  Yes

  No

  N/A

• Main Earth / Running Earth . Resistance in Ohms :

• Earthing System - Voltage to Independent Earth :

• Point of Shock - Voltage to Earth :

• Are all light and power circuits RCD Protected :

  Yes

  No

  N/A

• Socket Outlet Polarity Check :

  Pass

  Fail

  N/A

• Line Impedance:

Circuit; RCD Function, Insulation Resistance and Fault Loop Tests.

Circuit

• Circuit

  Select L1 P1 P2 P3 P4 P5 P6 L2 L3 L4 L5 O1 O2 O3 O4 O5 O6 O7 O8

  • L1
  • P1
  • P2
  • P3
  • P4
  • P5
  • P6
  • L2
  • L3
  • L4
  • L5
  • O1
  • O2
  • O3
  • O4
  • O5
  • O6
  • O7
  • O8

• RCD Protected

• Push Button Test.

• 30 mA Trip Time.

• Insulation Resistance.

• Fault Loop.

Additional tests in cases of shock from taps or water pipes.

• Continuity to Water Pipes. Resistance in Ohms :

• Voltage Under Load :

• Comparative Voltage. Main Switch Off , M.E.N Disconnected :

• A - N =

• A - E =

• Tradesman’s Name & Signature:

  Sign

• EW: