Electrical Injury Notification
THIS IS NOT AN INVESTIGATION REPORT! COMPLETE ASAP AND SUBMIT (<1 HOUR)

Submitting this notification will assist Berkeley Lab Health Services in determining the potential SEVERITY of an ELECTRICAL INJURY (electrical shock, arc flash or arc blast) and the necessary medical care followup.

If the person was taken to the emergency room, Health Services will ensure that medical professionals have the necessary information to administer all appropriate care.

After submitting the form, please call Health Services at x6266 to follow up (x6999 outside working hours), and the Lab ESO at 510-735-7367 (cell).

Email address *
Enter your phone number (cell preferred for texting) *
Your answer
Date of incident: *
MM
/
DD
/
YYYY
Name of injured person: *
Your answer
Organization injured person belongs to: *
Location of incident (Building number or other description) *
Your answer
Describe what happened to the best of your knowledge (short)
In two to three sentences, try to explain, if you know. What was the person doing at the time of the incident? How did the incident happen?
Your answer
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