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Electrical Accident Supplementary Details Form


If you would like to report a notifiable electrical accident, you should complete the Event Notification Formwhich will go directly into the Energy Safety Intelligence database. This form below has been provided to allow notifiers to provide additional accident details as required by regulation 106 of the Electricity Regulations 1997. This can be done online or by printing it out and posting or faxing it to us.

If you wish to retain a copy, print the form first (use "Save as PDF") and then to send it to Energy Safety (by pressing "Submit"). Submitting the form blanks the fields.

* indicates a mandatory field

Details of Victim
 
Gender
 
 
 
 
 
Place and Time of Incident
 
(dd/mm/yyyy)
 
 
AM/PM
 
Causes
 
 
Injuries
*
 
 
Medical Treatment? *
 
Was resuscitation applied?
 
 
Damage
 
 
 
Equipment involved
 
 
 
(dd/mm/yyyy)
 
 
Did it operate correctly?
 
Notifier
 
Notifier Relationship



 
 
 
 
 
(dd/mm/yyyy)
 

Caution: Submitting the form blanks the fields. If you wish to print the form (from "Save as PDF") and submit it on-line you should print it first.

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