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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
Gender


Place and time of accident
(dd/mm/yyyy)
AM/PM


Causes
Injuries
Injuries


Medical treatment?


Was resuscitation applied?


Damage
Equipment involved
(dd/mm/yyyy)
Did it operate correctly?


Notifier
Notifier association
What is your connection/relationship?
e.g. Police
(dd/mm/yyyy)
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.

Last updated 14 September 2012
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