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(Sit ruie 41A)

1. Datc and time of acciJeot

2, Place of accidcot, aad districr

3. Systern ap<I voll45c ofsuliply

4, Nalrc of tlic iicerisec or pcrson/persolrs or
supplier or rt.ler of encrgr io whose preoises
or jurisdictioa thc accidcnt occurred

5. (a) (i) Name of person

(ii) Ariimal (plcase;pecify Lhc name ar.d
aCdrcss of thc owner)

Namo of lrrsorri killed or injured

(b) Address of sucli/each perso!!

6.
:
Occ,.rpatic:r and dcsi3uaticn cf such persons/
pCf5,J;i

7. Bricf dcsaiirtiou o[ tiie jcb undcrtaken, if any

a Autlrority urrricr *hich such person/persor,s
u'as/werc ;rllow,:d trr wut l- t,n tlic.lob

Slatc alsrl wheCber he/tI:ey *'"1s/u'erE auiloriseti

pcrsot/peis...,r-is

Describe fully tlc ua(urE a*d exlent of lrjuries,

e.g fafd, dis*blcxrent oi any portion of licrJy or
othcr L:jury, cic.

10. Detailed c&ri.iffi lcad.ing to ttrc accident

11. Actioa takcn rcgai<li,4 first-aiJ/&ealical atteu-
darce, etc. imn:rerli,ricl'r aft:r thc o.;currence of
the acciileut

L2. Wiretiier appropriate Covernment, District

h{agistrate ard Poiicc Statiorr initrrmcd (if so,
givc the addr,-ss)

13. Steps takeu to prcserue the evidcnce in connec'

tioir with tire accirier,t, to the extcnt possitric.
.1

(ui)
74. Name aod des;#udcr,r's rli thc pcrioafs 1
ar*rsjia$ the per:oa1s tilicti or iniurcd

i5- S'&at safefy cryripmcr.C. r*crc 5ircir to an I t1

used b;r thc prsors ntrc cE t r'dth this accir-{cnt
(ag. ruLibcr EIrr.ns, rulfrer mai\ safcty belts
and ladders c.tc)

16. Whether isolating switc.hcs aed otl,er sectioua-

lising dcvices werc cmpioyed deadcn to
sectioos for working oa the sarne, if so, whethcr
lhcsc vrere earthed

77. Whether tEc work cn litc lincs were uuder-

taken uncler the direct supcnisioo ofauthorised
pcrsou, !f so, tlrc ra.flc anli dvsignation of thc
person uader whoss su5rcrvisic,a the work wa.r
rarrir:rl out
.b*:nt
18. Wherhcr artificial rcsuseitatioa triatseilt $?s
given tc thc person wlio mct nith clcclrical
accidcnt if ,to;,, for hou lcng was it contioucd
before it,r sban<Jonment

i9 Si,*ps piopr-sed it' L.c t,[cn to avoitl rr,crrrrcscc

m. Namar and dc.sigsationi of perscus prcscut

at the tiric r:rf acrridcnt

21. Any othrr rcmrri.s

Dated Si4naturc

Timc Narue

D esignaticin/Occu pation

Addrcss of the pcrson repqrting

(sd)

Comnrissioncr and Sccrctary to Gorcrnmcnt,

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