Electrical accident supplementary details form

Use this form to provide additional details to Energy Safety for an electrical accident.

If you would like to report a notifiable electrical accident, you should complete the Event Notification Form which 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 the Electricity (Safety) Regulations 2010 This can be done online or by printing it out and posting or faxing it to us.

Note | You must complete the fields that are marked with an asterisk *.

Details of victim

Name of victim

Gender

Male
Female

Address of victim

Age

Occupation

Company

Place and time of accident

Place of accident ■

Date of accident ■

(dd/mm/yyyy)

Time of accident

AM/PM

AM
PM

Causes

Description of accident ■

Possible cause(s) of accident

Injuries

Fatal
Non-fatal

Type of injuries

Medical treatment?

Yes
No

Was resuscitation applied?

Yes
No

Method of resuscitation (if yes)

Damage

Describe any damage or loss incurred by the accident

Name(s) of any witness, investigator or other person(s) who could provide information

Address and contact number

Equipment involved

Type of equipment involved

Voltage

Condition of the equipment involved

Date installed

(dd/mm/yyyy)

Type of electrical protection involved

Did it operate correctly?

Yes
No

If "No", state reason it did not operate

Notifier

Name of person reporting the accident ■

Notifier association

What is your connection/relationship?

Owner

Occupier

Reg.Person

Employer

Other relationship

e.g. Police

Company

Telephone ■

Email ■

Date ■

(dd/mm/yyyy)

Address

Verification: Please type the word 'electrical' ■

To help us reduce spam please type the word 'electrical' in the field below.

Please note

If you wish to retain a copy of this form, select first the "Generate as PDF" button to save or print a copy.

To send the form to Energy Safety select the “Submit accident details“ button. Please note that submitting the form clears all entered data, and you will no longer be able to save a copy.

Generate as PDF

Online forms for detailing notified events

Electrical accident supplementary details form