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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