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Fax Anonymous Registry (FAR) Project

for Electrical Incidents 

FAX Anonymous Registry (FAR) Project for Electrical Incidents

 

 

If you have information about an electrical incident, please complete the following anonymously.

Fax the completed form to USA 262-552-2902. (The old area code is 414).

Call confidentially with questions to Dr. Mary Capelli-Schellpfeffer at USA 773-960-5802. (You may wish to E-mail questions to capschell@capschell.com)

When did the electrical incident occur?

YEAR_____ MONTH______

Day of week: Time of day:

________Unknown         ________Unknown

________Monday          ________Daylight

________Tuesday         ________Dusk

________Wednesday    ________Dark

________Thursday        ________Dawn

________Friday

________Saturday

________Sunday

What was the voltage of the electrical source?

_________Volts

_________Unknown

 

What was the current of the electrical source?

_________Amperes

_________Unknown

At what kind of location did the electrical incident occur?

________Unknown

________Boating

________Construction

________Demolition

________Farm

________Home

________Manufacturing

________Military

________Mining

________Park

________Plant

________Public Building

________Outdoors/Home Yard

________Recreation Area

________Renovation

________School

________Other. Please explain:

 

What kind of electrical source was involved in the electrical incident? (Please check all that might apply.)

________Unknown

________Static

________Grounding

________Overhead power line

________Underground power line

________Water over power line

________Water under power line

________Water near electrical power tool or equipment

________Motor control center

________Control equipment

________Switchgear

________Heat trace

________Portable equipment

________Lighting

________Welding

________Cable tray

________Drives

________Motors

________Plug in buss duct

________Other. Please explain:

 

Was a person present at the electrical incident?

________Unknown

________No.

________Yes, the incident was attended.

 

If yes, how many were present?

________1

________2

________3

________4

________5

________More than 5

 

What was the status of those present?

________No one was present.

________Unknown

________Employees of the location

________Contractors at the location

________Other. Please explain:

 

What kinds of jobs were being done?

(Please check all that apply.)

________Unknown

________Design

________Electrician

________Engineer

________Equipment Operator

________Heating & Ventilation

________Home repair

________Instrument & Electronics Technician

________Laborer

________Machinist

________Maintenance

________Plant Operator

________Pipefitter

________Thermographic

________Architectural

________Civil Engineering

________Other. Please explain:

What kinds of hazards were present at the incident? (Please check all that apply.)

________Unknown

________Arc

________Confined space

________Electrical shock

________Explosion

________Falls or work at heights

________Fire

________Flash

________Operating or moving equipment

________Other. Please explain:

 

 

 

Was the presence of hazard identified before the incident?

________Unknown

________No.

________Yes. Please explain:

 

 

 

 

 

 

E-mail questions to:

capschell@capschell.com

Was someone killed at the scene of this electrical incident?

________ Unknown.

________ No.

________ Waiting for medical information.

________ Yes. How many people were killed?______

 

Was someone injured at the scene of this electrical incident?

________ Unknown.

________ No.

________ Waiting for medical information.

________ Yes. How many people were injured?______

 

If people were injured, please describe or check all that apply.

________Only first aid required at the incident scene

________First aid/emergency room care was required.

________Hospital admission was required for one or more.

 

What Kinds of problems did people report?

________Burns ________Other. Please

________Blast injury explain:

________Brain injury

________Crush injury

________Fall injury

________Nerve injury

________Shrapnel injury

 

Fax completed form to USA 262-552-2902.

 

 

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Last modified: January 12, 2004