Electric And Communication Incident Report Page 2
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3Personal Injury or Contact Information (Cont.)
Section 2 (Written Notice – within 20 days – Sections 1 and 2)
Weather Conditions (check one in each group):
Hot
Warm
Cool
Cold
Light
Dim
Dark
Dry
Fog
Light Rain
Rain
Wind: Heavy
Light
Calm
Visibility: Clear
Impeded by ____________________________________________________________
Area Type (check one or more):
Rural
Suburban
Urban
Industrial
Construction Site
Other _______________________
General Activity (check one or more):
Construction
Maintenance
Utility Work
Logging
Agriculture
Recreation
Residential Work
Travel
Other __________________________________________
Contact Type (check one or more):
*Lift
*Crane
Antenna
Tree
Sign
Roof
Boat Mast
Air Collision
Pole
Climbing Structure
Kite
Dig In
Pipe
Body
Wire Down
Other ________________
COMMENTS: ______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
*Definitions and commonly used abbreviations
OH
=
Overhead power lines
UG
=
Underground power lines
Lift
=
Includes forklifts, man lifts, etc.
(A fork, platform, or basket supports the load)
Crane
=
Equipment designed to lift and move loads by means of a rope or cable
(Also includes hydraulic booms like that used for pumping cement)
Emergency room treatment is not considered “hospitalization”
Hospitalized
=
Minor Injury
=
Includes emergency treatment and release, first aid treatment, minor injury requiring no
treatment, and other similar situations
Reporting Information & Phone/Fax Numbers
For reporting during normal working hours, the information can be faxed to the PUC’s Safety, Reliability, and Security
Division at (503) 378-5505.
Mail reports to: Administrator, SRSD, Oregon PUC, 201 High St. SE, P.O. Box 1088, Salem, OR 97308-1088
For those accidents involving fatalities and critical injuries only, we urge that you contact the PUC safety personnel that
are on 24 hour duty at telephone number (503) 378-6964 at the earliest practicable moment. The call will be routed
automatically to the on-duty safety person.
Reports can also be e-mailed to puc.esafety@state.or.us. This is a group address that will send your e-mail to each
member of the electrical and communications safety staff.
PUC Form FM 221 (Rev. 08/07/2015)
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