Electric And Communication Incident Report

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ELECTRIC AND COMMUNICATION INCIDENT REPORT
(OAR 860-024-0050 (See Page 3 for definitions)
PUBLIC UTILITY COMMISSION OF OREGON
Instructions: Fill in the appropriate sections.
Reporting Information & Phone Numbers
Check options and fill in blanks.
Section 1 (Immediate Notice – Phone/Fax)
For PUC Staff Only
Time Received _____:_____a.m./p.m. Date _____/_____/_____ Received By ________________________________
Utility or Operator ___________________________________ Reported By ____________________________________
Phone Number (
)
Incident Date ____/____/____ Time ____:____a.m./p.m.
Location of Incident – City _______________________ County ___________ Address or Directions ______________
_________________________________________________________________________________________________
Description of Incident ______________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Personal Injury or Contact Information
Property Damage
Name ________________________________ Age____ Sex: M
F
(over $100,000)
Estimated amount $__________
Injury Severity: Fatal
*Hospital
*Minor Injury
No Injury
Name ________________________________ Age____ Sex: M
F
Service Outage
Injury Severity: Fatal
*Hospital
*Minor Injury
No Injury
Date_____/_____/_____
Time Out __________a.m./p.m.
Name ________________________________ Age____ Sex: M
F
Time In __________a.m./p.m.
Injury Severity: Fatal
*Hospital
*Minor Injury
No Injury
Customers Out __________
Name ________________________________ Age____ Sex: M
F
Number of Circuits __________
Injury Severity: Fatal
*Hospital
*Minor Injury
No Injury
Reportable:
Utility serving over 15,000 cus-
tomers with 500 customers or
Facility Type: *OH
*UG
Substation
more out over two hours.
Other ____________________ Voltage: _____________
Utility serving less than 15,000
customers with 500 customers
Worker’s Trade: _____________________
Work Related: Yes
No
or more out over five hours.
Exception:
Employed By: ________________________________________________
Not reportable if outage is
Utility notified of activity prior to incident: Yes
No
restricted to a single feeder and
outage is less than four hours.
PUC Form FM 221 (Rev. 08/07/2015)
1

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