Incident Investigation

• Prepared by

• Conducted on

  Date

• Location of Incident

Date/Time/Location of Incident

• Date/Time of Investigation

  Date

• Date/Time Investigator was notified

• GPS coordinates
  Address

• Pole number(s)

• Building Number(s)

• Street

• Cross Street

• Town

• State

On-site Personnel

• Were outside parties present during your investigation

  Yes

  No

  N/A

• Police

• Officer Name and Department

• Fire

• Name and Department

• Fire Marshall

• Name and Department

• OSHA

• Name of inspector

• Others

• Describe

• Were MOREC employee(s) present during your investigation

  Yes

  No

  N/A

• Name of employee(s)

Injured Party Information

• Name

• Sex

• Age

• Address of injured party

• Phone number

• Injured party's employer

• Description of injuries and his/her general condition

• Description of clothing

• Was victim wearing appropriate PPE

  Yes

  No

  N/A

• What PPE was missing

• Who provided onsite medical treatment and transport to medical treatment facility for victim

• Name of medical facility where injured party was sent for treatment

• Injured party's attending physician

• Normal occupation of injured party

• Time spent in that occupation

• Was the injured party working in their normal occupational capacity at time of incident

  Yes

  No

  N/A

• Qualifications to do work involved in at time of incident

Witnesses

• Name, addresses and phone numbers of witnesses

Weather Data

• Day/Time of incident

• Temerature

• Cloud cover

  Yes

  No

  N/A

• Wind velocity

• Wind Direction

• Day/Time of investigation (when measurements were recorded)

• Temerature

• Cloud cover

  Yes

  No

  N/A

• Wind velocity

• Wind Direction

Incident Reconstruction

• Position of injured party at time of incident

• Activity of injured party at time of incident (working alone or with others, description of activity)

• Events leading up to incident

• Were there objects or equipment involved in the incident

  Yes

  No

  N/A

• Nameplate data

• Measurements of object or equipment

• Measurements of point of contact

Description of Electrical System Involved

• Feeder and Phase(s)

• Voltage

• Amps

• Wire/Conductor Description

• Pole Information

Clearance Information

• Distance between poles where incident occured

• Height of phase and neutral conductor attachment points (both poles)

• Vertical clearance mid span for phase and neutral

• Vertical clearance at lowest point in the span for phase and neutral (if not mid span)

• Horizontal clearances for phase and neutral to building or structure

Additional Information and Pictures

• Additional Information

• Additional Photos

  Media

• Additional Photos

  Media

• Additional Photos

  Media

• Additional Photos

  Media

• Additional Photos

  Media