Title Page
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Site conducted
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Document No.
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Conducted on
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Employee completing investigation
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Division
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Location
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Type of Event
- Good Catch
- Near Miss
- CESR Deficiency
- Outage
- Vehicle Accident
- Utility Strike
- Injury
- Chemical Spill
- Property Damage
- Significant Safety Violation
- Theft
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Feeder crew working on:
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Feeder crew working on:
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Feeder crew working on (if applicable):
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Feeder crew working on:
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The utility owner must be contacted within an hour
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Employee must complete a drug and alcohol screening within 2 hours
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Did the employee complete a police report?
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Employee must complete a drug and alcohol screen within 2 hours of the event.
Event Information
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Crew Member(s) involved
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Foreman of crew
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Describe in detail what happened. (add as much detail as possible)
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Add photo(s) of the incident (if applicable). Photos shall be added for all vehicle accidents, CESR Deficiencies and events, Utility Strikes, Good Catches, Near Misses and Property Damages (including environmental spills)
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What repairs were made?
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Add photo(s) of any repairs made (if applicable)
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How could the event been prevented? (Detailed description)
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Was the controlling utility contacted about the event (if applicable)?
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Name (and Phone Number) of Contractor Oversight that was notified
