In case of contravention of these rules, an applieation shall be filed against the person contravening the rules by the Inspector under Section 146 of the Act before the competent court.
858 iTarsrkw , glich 24 1-i 2016 [ ITP1 4 (7).
FORM [See Rule 3 WI FORM FOR REPORTING ELECTRICAL ACCIDENTS Date and time of accident Place of accident (Village/Town, Tehsil/Thana, District).
System and voltage of supply [More than 650 volts/650 volts/250 volts Line, Sub-station/generation station/service lines/consumer's installations/other installation] Designation of the officer-in-charge of the generating company/licensee in whose jurisdiction the accident occurred Name of owner/user of energy, in whose premises the accident occurred Details of victim (s) (Human / Animal).
(A)Human St No. Name Father's Name Male/ Female/ Transgender Full postal address Approximate Age Fatal/ nonfatal
(1) (2) (3) (4) (3) (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) (3) (6) In case the victim (s) is/are employee (s) of supplier designation of such person (s);
brief description of the job (s) undertaken, in any;
MPT 4 CIO ] WM-kW qiich 24 13 2016 859
(c) whether such person/persons was/ were allowed to work on the job?
8. In case the victim(s) is/are employees of a licensed contractor,-
(a) did the victim (s) possess any electric workmen's permit (s), supervisor's certificate of competency? If yes, name of issuing officer and its number and date.
(b) name and designation of person who assigned the duties to the victim(s).
9. In case of accident in the system of the supplier, . whether the permit to . work (VFW) was taken?
10. (a) Description, nature and extent of injurieS, e.g. fatal/disablement . (permanent or temporary) or burns or other injuries of any portion of the body.
(b) Whether the postmortem done in case of death in Fatal accidents.
Detailed cause leading to the accident. • (To be given in a separate sheet annexed to this form).
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 informed of the accident (If so, give details).
14. Steps taken to preserve the evidence in connection with the accident, to the extent possible.
Name and designation(s) o•f the person(s) assisting, supervising the person(s) died or injured.
What safety equipments were given to or used by the person(s) who met with this accident (e.g. rubber gloves, rubber mats, safety belts and ladders etc.)?
.860 Re215t4Ttivir I-f$r4, 24 aff 2016 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?
Whether the work on the live lines was undertaken by authorized person
(s)? if so, the name and the designation of such person (s) may be given.
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?
Names and designation's of persons present at, and witnessed, the accident.
Any other:information/remarks.
Place Signature Time Name Date Designation Name of the person submitting the report tfut14IM t¶14 tr 2.r7 atrr-§Trz
311.1:11.t. yii , SITSG 00000001 00000002 00000003 00000004 00000005 00000006 00000007 00000008 00000009