WORKPLACE ELECTRICAL SAFETY INCIDENT REPORT
Date of Incident: [2053-05-15] | Incident Time: [10:30 AM] |
Incident Location: [Main Electrical Room] | Incident Report ID: [#WESIR-2023-001] |
Name of Employee Involved: [John Davis] | Employee's Job Title: [Maintenance Technician] |
Employee's Contact Information: [555 -6789] |
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.
Electrical Equipment Involved
Equipment Type: Circuit breaker
Equipment Serial/ID Number: CB-78901
Equipment Manufacturer: PowerSafe Inc.
Date of Last Inspection: 2053-03-10
Injuries or Damages
Injuries Sustained: Employee John Davis sustained a minor electrical shock but did not require hospitalization.
Property Damage: No property damage was reported.
Actions Taken
First Aid Provided: Employee John Davis received immediate first aid on-site.
Medical Treatment: Although minor, Employee John Davis was examined by our company's medical personnel as a precaution.
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.
Investigation: An internal investigation will be conducted to determine the root cause of the incident.
Preventive Measures
A. Recommendations to Prevent Recurrence
Ensure that all electrical equipment is properly inspected and maintained regularly.
Reinforce safety training for employees working with electrical systems.
Supervisor's Report
Supervisor's Name: [Your Name]
Supervisor's Signature: ______________________
[2053-05-15]
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