Electrocution

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Text in this Example:

ELECTRICAL
NAME OF DECEDENT:
This form is to be completed in addition to the ROD form in these guidelines
(INSURE THAT ALL QUESTIONABLE EQUIPMENT, APPLIANCES, TOOLS, OR SITE IS SECURED BY
APPROPRIATE AGENCY UNTIL IT CAN BE MADE SAFE.) DO NOT GO WITHIN 20 FEET OF A FALLEN
WIRE. GET ASSISTANCE OF POWER COMPANY. LIGHT UP THE AREA AND MARK IT OFF. KEEP AWAY FROM OVERHEAD WIRES. KEEP MOTORISTS IN VEHICLES. DO NOT USE DAMP POLES, ETC., TO LI FT WIRES. DO NOT LET ANYONE GET INTO A CIRCUIT BETWEEN ONE WIRE AND ANOTHER OR BETWEEN ONE WIRE AND THE GROUND.
DESCRIBE WHERE THE DECEDENT IS FOUND RELATIVE TO ANY ELECTRICAL APPLIANCES OR
APPARATUS IN THE IMMEDIATE AREA:
WHAT WAS DECEDENT DOING AND HOW WAS CONTACT MADE WITH THE ELECTRICAL OBJECT?
IS IT GROUNDED:
3-WIRE PLUG
3 -WIRE SOCKET
TYPE OF POWER:
110 VOLTS AC
220 VOLTS AC
440 VOLTS AC
OTHER:
CIRCUIT PROTECTIONS:
FUSE
CIRCUIT BREAKER
INTERLOCK
WHAT IS THE VISIBLE CONDITION OF THE APPARATUS?
IF PROTECTIVE DEVICES WERE PRESENT, WERE THEY BYPASSED IN ANY WAY?
IS THERE ANY EVIDENCE ON THE APPARATUS OR ON THE BODY OF SPARKS OR FIRE?
HAS ANYONE EVER RECEIVED A SHOCK OR INJURY FROM THE APPARATUS IN THE PAST?
IS THERE ANY STANDING WATER/LIQUID IN THE IMMEDIATE AREA?
IF SAFETY EQUIPMENT IS PRESENT, IS THERE ANY INDICATION THAT THE SAFETY EQUIPMENT IS
DEFECTIVE (EXPLAIN)?
IF BODY IS EXAMINED BY YOU, DESCRIBE THE ENTRY AND EXIT POINTS OF THE CURRENT BEING
SPECIFIC AS TO ARTIFACT ON THE BODY:
(APPLIANCES OR DEFECTIVE SAFETY GEAR ARE TO BE PHOTOGRAPHED AND IF IT IS NOT POSSIBLE TO RENDER THEM SAFE, SHOULD BE TURNED OVER TO THE APPROPRIATE AGENCY FOR TESTING AND FURTHER HANDLING - IF IT IS A PORTABLE APPLIANCE, LAW ENFORCEMENT SHOULD BE ENCOURAGED TO SEEK OUT APPROPRIATE TESTING. IF THE APPLIANCE OR SAFETY MATERIAL IS NOT PORTABLE, THE LOCAL ELECTRIC COMPANY SHOULD BE CALLED ON TO EXAMINE IT AND RENDER IT SAFE.)
NAME OF INVESTIGATOR
DMI#