Workplace Electrical Safety Incident Report
WORKPLACE ELECTRICAL SAFETY INCIDENT REPORT
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Date of Incident: [2053-05-15] |
Incident Time: [10:30 AM] |
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Incident Location: [Main Electrical Room] |
Incident Report ID: [#WESIR-2023-001] |
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Name of Employee Involved: [John Davis] |
Employee's Job Title: [Maintenance Technician] |
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Employee's Contact Information: [555 -6789] |
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Incident Details
Description of the Incident: On May 15, 2023, at approximately 10:30 AM, while performing routine maintenance in the Main Electrical Room, Employee John Davis received an electrical shock when he accidentally touched an exposed wire. The incident occurred due to a faulty circuit breaker that was not properly isolated.
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Were Safety Protocols Followed? Yes
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List of Witnesses: None
Electrical Equipment Involved
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Equipment Type: Circuit breaker
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Equipment Serial/ID Number: CB-78901
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Equipment Manufacturer: PowerSafe Inc.
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Date of Last Inspection: 2053-03-10
Injuries or Damages
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Injuries Sustained: Employee John Davis sustained a minor electrical shock but did not require hospitalization.
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Property Damage: No property damage was reported.
Actions Taken
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First Aid Provided: Employee John Davis received immediate first aid on-site.
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Medical Treatment: Although minor, Employee John Davis was examined by our company's medical personnel as a precaution.
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Repairs/Replacements: The faulty circuit breaker, serial number CB-78901, was isolated and tagged out of service. It will be sent for repairs and replaced temporarily with a properly functioning unit.
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Investigation: An internal investigation will be conducted to determine the root cause of the incident.
Preventive Measures
A. Recommendations to Prevent Recurrence
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Ensure that all electrical equipment is properly inspected and maintained regularly.
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Reinforce safety training for employees working with electrical systems.
Supervisor's Report
Supervisor's Name: [Your Name]
Supervisor's Signature: ______________________
[2053-05-15]
