Shared Services Accident Investigation Report

• Conducted on

  Date

• Prepared by

• 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

• Cooperative Name

• Type of Accident/Incident

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Date and time of this report

  Date

• Date and time of the accident/incident

  Date

• Date and time the cooperative was notified of the accident/incident

  Date

• Name of person(s) injured

• Select Electric Cooperative Employee Non Electric Coopertive Employee (member of the public) Contractor working for the electric cooperative

  • Electric Cooperative Employee
  • Non Electric Coopertive Employee (member of the public)
  • Contractor working for the electric cooperative
• Location of the accident/incident. Type in the physical address if not able to use location detection.
  Address

• Take a screen shot of the general location and annotate exact location of accident/incident

  Media

• Name(s) of accident/incident investigation team

• Was law enforcement involved?

  Yes

  No

• If yes, was a police report filled out?

  Yes

  No

• Name of officer and police department if known

Environmental Conditions

• Weather conditions?

  Sunny / Clear

  Raining

  Overcast

  Snow

  Ice

• Air Temperature - Degrees Fahrenheit

  Below Zero

  Zero - 32

  33 - 50

  51 - 70

  71 - 100

• Wind Speed - Miles per hour

  Zero - 15

  16 - 20

  17 - 25

  26 - 35

  36 - 50

• Terrain Conditions

  Normal

  Muddy

  Hills

  Ice

  Depressions/Holes

Equipment Involved

• Commercial Motor Vehicle

• Non Commercial Motor Vehicle

• Excavating Machinery

• Private Industry Vehicle/Equipment

• No Equipment Involve

• Add media

  Media

Witness information

• Was there a witness(s) to the accident/incident?

  Yes

  No

• if yes, list the name of the witness(s)

• Select one of the following

  Select Electric Cooperative Employee Non Electric Coopertive Employee (member of the public) Contractor working for the electric cooperative

  • Electric Cooperative Employee
  • Non Electric Coopertive Employee (member of the public)
  • Contractor working for the electric cooperative

• Witness contact information

• Did the witness fill out a written statement of the accident/incident?

  Yes

  No

Accident/Incident Detail

• Describe in detail what happened

• Add drawing

  Drawing

• Add drawing

  Drawing

• Add media

  Media

• Add media

  Media

Injuries

• Select Laceration Bruise Blunt Force Trauma Amputation Electric Shock Burns - Arc Flash or Fire Crushed No injury received

  • Laceration
  • Bruise
  • Blunt Force Trauma
  • Amputation
  • Electric Shock
  • Burns - Arc Flash or Fire
  • Crushed
  • No injury received

• Victim(s) was/were transported to a medical facility

• Medical Facility Name

• There was blood borne pathogen exposure

• First aid was provided onsite

• No medical or first aid help was needed

• Additional Information

Electric System Affected

• Electric system was not affected

• Electric system outage occurred

• Electric System Information (Substation, breaker, voltage, number of operations, conductor size etc.)

• Damage to electric system structures occurred

• Description of damage

• Was breaker set to non re-close?

  Yes

  No

  N/A

Reporting Requirements

• Cooperative Was Notified

• Shared Services Compliance Was Notified

• OSHA Was Notified

• Insurance Provider Was Notified

Root Cause Analysis

• Was the victim able to be interviewed?

  Yes

  No

• Were there violations to operating procedures, work practices or other pertinent regulations?

  Yes

  No

• Describe the violations in detail

• Was there evidence gathered at the location of the accident/incident?

  Yes

  No

• Description of the evidence

• Root Cause as determined by the information gathered

• Mitigation Suggestions to prevent this accident/incident from happening again?

Signatures of Accident Investigation Team

• Ben Bella

  Sign

• Add signature

  Sign

• Add signature

  Sign

• Add signature

  Sign

• Add signature

  Sign