Utility Damage Report

Utility Damage Report

Instructions: This report is to be completed by the jobsiteforeman/supervisor forwarded to managementby the end of the next business day.

DO NOT SPECULATE AS TO WHY THIS DAMAGE OCCURRED. DESCRIBE WHAT HAPPENED IN DETAIL ONLY.

General Information
Date of damage
_____ /_____ /____
MM / DD / YYYY / Time of Damage
____:____
AM PM / PERSONNEL
AREA MANAGER:
SUPERVISOR:
FOREMAN:
Address of damage / City / State / Zip
Did you report the damage to…. date and time
Management / Yes / No / If yes, Name:
Safety Coordinator / Yes / No / If yes, Name:
Customer / Yes / No / If yes, Name:
Facility Owner / Yes / No / If yes, Name:
Other / Yes / No / If yes, Name:
validone call / locate ticket number prior to excavating? Yes No
If yes, enter number:
Type of work being done? (gas, electric, water, sewer, etc.)
Work being done for what customer?
Were there any injuries?
yes no if yes, also complete an injury report / Did anyemergency personnel respond to the damage / incident?
yes no if yes, Identify:
Was anevacuationnecessary?
Yes no if yes, explain: Who ordered? / Wastrafficstopped or detoured?
yes no if yes, explain:
Utility Damage Details
was the utility marked?
Name of utility company damaged: / Marked
how was it marked?
(paint, flag, stake, other) / Un-marked / mis-marked
how far off were the marks?
_____ feet _____inches
how was it marked?
(paint, flag, stake, other)
damage location
Underground
depth at damage ______feet ______inches
Above ground / Type of damage
(cut, impact, pulled, fire, other, etc.)
Type of Utility (electrical, cable, gas, water, sewer, other, etc.
Type of Service (main, service, other, unknown, etc.)
Duration of service Interruption (hours / minutes)
damaged utility:
material type: (steel, plastic, etc.
pressure (psig/inches)
size (diameter, voltage, pairs, etc.)
Name & contact information of utility personnel who responded?
Repair information – done by the utility company
How many people responded?
# of vehicles involved?
Major equipment involved?
Major materials involved?
Additional remarks / comments about the type and extent of damage
Damage caused by:specifically describe equipment which caused damage:
(example, backhoe, shovel, jackhammer, etc.)
Name of employee Operating equipment or tool that caused damage______
site conditions and weather at the time of incident:
Description of the incident. what happened? please be specific and include as many details as possible. Include such things as what you saw, heard, observed. attach additional sheets if necessary. also, use this section to identify and note any comments made by utility / locating personnel while at the scene. DO NOT SPECULATE AS TO WHY. DESCRIBE WHAT HAPPENED IN DETAIL ONLY.
Witness Information
Name / Address / Phone number
Did you take a minimum of 24 pictures? / Yes No / if no, explain why?
Do Photos show the damage? / Yes No / if no, explain why?
Photos show depth of damage with a measuring device? / Yes No / if no, explain why?
Photos show mis-marked areas with a measuring device? / Yes No / if no, explain why?
Photos show date of damage? / Yes No / if no, explain why?
Did you get witness statements? / Yes No / if no, explain why?
Down Time Details
Name and title of all crew members on site:
All Equipment, Vehicles and trailers on site:
Amount of time delay: / did we assist in the repair in any way? Yes No If yes, explain:
Report Preparer
report prepared by: (print name) / job title: / phone number: / date prepared:
preparer signature:
SKETCH OF SITE AND DAMAGE
provide a detailed sketch of the area: To accurately describe the incident, please include the following:
(1) direction of north
(2) the underground utilities using solid lines; label by type (gas, water, phone, etc.)
(3) location of incident using fixed distance landmarks (transformer, poles, peds, gas meter, etc.)
(4) the location of the marks using dashed linesplaced by utility/locator; label by type and color of marking)
(5) the distance between the incident and the marks.
(6) Closest Road/street or Direction to closest road/street
(7) drawing needs to fit in the area below provided
solid lines for utilities, dashed lines for location marks, x for damage location, Indicate North by arrow

Witness Statement Form

(To be completed by the witness)

Location of Incident:

Date of Incident:Time of Incident:

Your Name:

HomeAddress:

Phone:

Your Company Name:

Your Job Title:Your Supervisors Name

PLEASE PRINT. Give a factual statement of YOUR actions & observations, preceding, during and following the occurrence. Use additional pages if needed.

DO NOT SPECULATE WHY, DESCRIBE (IN DETAIL) WHAT HAPENNED ONLY.

______

Names of others with knowledge of occurrence:

Signature:Date: