Annexure G


(See rules 44-A)
1    Date and time of accident.
2    Place of accident
      (Village/Town, Tehsil/Thana, District and State).
3    System and voltage of supply, (Whether EHV/HV/LV Line, Sub-station/generating
       station/consumer's installations/service lines/other installations.
4.    Designation of the Officer-in-charge of the supplier in whose jurisdiction the accident occurred.
5.    Name of owner/user of energy in whose premises the accident occurred.
6.    Details of victim(s) :--

Sl. No. Name Father's Name Sex of victim Full Postal Address Approximate age Fatal / Non-fatal
1 2 3 4 5 6 7

(b) Animal

Sl. No. Description of animal(s) Number(s) Name(s) of owner(s) Address(es) of owner(s) Fatal / Non-fatal
1 2 3 4 5 6

7    In case the victim(s) is/are employee(s) of Supplier :-
a) Designation of such person(s).
b) Brief description of the job undertaken, if any
c) Whether such person/persons was/were allowed to work on the job.
8    In case the victim(s) is/are employee(s) of a licensed contractor :--
a) Did the victims(s) possess any electric workman's permit(s), supervisor's certificate of competency issued under rule 45? If yes give number and date of issue and the name of issuing authority.

b) Name and designation of the person who assigned the duties of the victim(s).
9    In case of accident in the supplier's system, was the permit to work (PTW) taken?
10.    a) Describe fully the nature and extent of injuries, e.g. fatal/disablement (permanent or temporary) of any portion of the body or burns or other injuries.

b) In case of fatal accident, was the post mortem performed?
11.    Detailed causes leading to the accident. 
(To be given in a separate sheet annexed to this form).
12.    Action taken regarding first-aid, medical attendance etc. immediately after the occurrence of the accident (give details).
13.    Whether the District Magistrate and Police Station concerned have been notified to the accident (if so, give details)
14.    Steps taken to preserve the evidence in connection with the accident to extent possible.
15.    Name and designation(s) of the person(s) assisting, supervising the person(s) killed or injured.
16.    What safety equipments were given to and used by the person(s) who met with this accident (e.g. rubber gloves, rubber mats, safety belts and ladders etc)?
17.    Whether isolating switches and other sectionalizing devices were employed to deaden the sections for working on the same? Whether working section was earthed at the site of work?
18.    Whether the work on the live lines was undertaken by authorised person(s)? If so, the name and designation of such person(s) may be given.
19.    Whether artificial resuscitation treatment was given to the person(s) who met with the electric accident? If yes, how long was it continued before its abandonment?
20.    Names and designations of persons present at and witnessed the accident.
Any other information remarks.



                                                                                                                              Address of the person reporting

Last Updated Date :- 07-12-2018

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