Title Page

  • Conducted on

  • 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

  • Date and time of this report

  • Date and time of the accident/incident

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

  • Name of person(s) injured

  • Location of the accident/incident. Type in the physical address if not able to use location detection.
  • Take a screen shot of the general location and annotate exact location of accident/incident

  • Name(s) of accident/incident investigation team

  • Was law enforcement involved?

  • If yes, was a police report filled out?

  • Name of officer and police department if known

Environmental Conditions

  • Weather conditions?

  • Air Temperature - Degrees Fahrenheit

  • Wind Speed - Miles per hour

  • Terrain Conditions

Equipment Involved

  • Commercial Motor Vehicle

  • Non Commercial Motor Vehicle

  • Excavating Machinery

  • Private Industry Vehicle/Equipment

  • No Equipment Involve

  • Add media

Witness information

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

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

  • Select one of the following

  • Witness contact information

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

Accident/Incident Detail

  • Describe in detail what happened

  • Add drawing

  • Add drawing

  • Add media

  • Add media

Injuries

  • 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?

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?

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

  • Describe the violations in detail

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

  • 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

  • Add signature

  • Add signature

  • Add signature

  • Add signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.