Title Page
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Use this form to report electric cooperative employee or public accidents/incidents including: public liability or electrical contact, property damage investigation, near miss/close call incidents, first aid and loss time accidents
General Information
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Cooperative Name
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Type of Accident/Incident
- First Aid Incident
- Serious Injury or Fatality
- Near Miss/Close Call
- Damage to Cooperative or Private Property
- Public Liability - Electric Contact, Damage to Cooperative Property etc.
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Date and time of this report
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Date and time of the accident/incident
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Date and time the cooperative was notified of the accident/incident
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Name of person injured
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- Electric Cooperative Employee
- Non Electric Coopertive Employee (member of the public)
- Contractor working for the electric cooperative
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Location of the accident/incident. Type in the physical address if not able to use location detection.
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Take a screen shot of the general location and annotate exact location of accident/incident
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Name(s) of accident/incident investigation team
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Was law enforcement involved?
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If yes, was a police report filled out?
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Name of officer and police department if known
Environmental Conditions
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Weather conditions?
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Air Temperature - Degrees Fahrenheit
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Wind Speed - Miles per hour
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Terrain Conditions
Equipment Involved
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Commercial Motor Vehicle
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Non Commercial Motor Vehicle
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Excavating Machinery
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Private Industry Vehicle/Equipment
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No Equipment Involve
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Witness information
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Was there a witness to the accident/incident?
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if yes, list the name of the witness
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Select one of the following
- Electric Cooperative Employee
- Non Electric Coopertive Employee (member of the public)
- Contractor working for the electric cooperative
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Witness contact information
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Did the witness fill out a written statement of the accident/incident?
Accident/Incident Detail
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Describe in detail what happened
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Injuries
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- Laceration
- Bruise
- Blunt Force Trauma
- Amputation
- Electric Shock
- Burns - Arc Flash or Fire
- Crushed
- No injury received
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Victim was transported to a medical facility
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Medical Facility Name
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There was blood borne pathogen exposure
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First aid was provided onsite
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No medical or first aid help was needed
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Additional Information
Electric System Affected
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Electric system was not affected
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Electric system outage occurred
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Electric System Information (Substation, breaker, voltage, number of operations, conductor size etc.)
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Damage to electric system structures occurred
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Description of damage
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Was breaker set to non re-close?
Reporting Requirements
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IAEC Was Notified
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IUB Was Notified
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OSHA Was Notified
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Insurance Provider Was Notified
Root Cause Analysis
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Was the victim able to be interviewed?
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Were there violations to operating procedures, work practices or other pertinent regulations?
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Describe the violations in detail
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Was there evidence gathered at the location of the accident/incident?
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Description of the evidence
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Root Cause as determined by the information gathered
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Mitigation Suggestions to prevent this accident/incident from happening again?
Signatures of Accident Investigation Team
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John Dvorak
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Matt Pociask
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Jim Wolfe
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Scott Meinecke
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