DJ Mc? Utility Damage Report

• Job # / Street Name

• Conducted on

  Date

• Prepared by

Job Info

• Job #

• Road/Street Name

• Town

• Nearest address & stationing to hit

• Nearest Intersection to hit

• Nearest Intersection to hit

• What side of road was utility hit on

  North

  South

  East

  West

Miss Dig Ticket Info

• Was Miss Dig Called Prior To Digging

  Yes

  No

  Unknown

• Miss Dig Ticket #

• Miss DIg Ticket Call In Date/Time

  Date

• Restake Date/Time

  Date

Damage Info

• Date and time of damage

  Date

• Damaged Utility

  Select Gas Phone Underground Electric Overhead Electric Cable DSL Water Sewer storm/culverts Irrigation Other

  • Gas
  • Phone
  • Underground Electric
  • Overhead Electric
  • Cable
  • DSL
  • Water
  • Sewer
  • storm/culverts
  • Irrigation
  • Other

• Utility Owner

• Photo identifying location

  Media

• Photo of damage

  Media

• Photo of markings in area

  Media

• Additional photo if applicable

  Media

• Sketch of damage

  Drawing

• Was damaged utility marked?

  Yes

  No

  N/A

• Was utility marked properly?

  Yes

  No

  N/A

• How many feet was the utility from the nearest flag?

• Was the utility potholed?

  Yes

  No

  N/A

• Describe damage and circumstances

• Crew members involved

• Equipment Involved

  Select Backhoe/Excavator Dozer Grader Loader/Skidsteer Scraper Mill/Pulverizer Trencher Hydro Vac Hand Tools Other

  • Backhoe/Excavator
  • Dozer
  • Grader
  • Loader/Skidsteer
  • Scraper
  • Mill/Pulverizer
  • Trencher
  • Hydro Vac
  • Hand Tools
  • Other

• Type of Work Being Performed

  Select Removal of culvert,curb,etc Removal of Trees, Stumps Placing Silt Fence Stripping Topsoil Subbase/Excavation Placing Pipe Roadway Grading Milling/Pulverizing Trenching Other

  • Removal of culvert,curb,etc
  • Removal of Trees, Stumps
  • Placing Silt Fence
  • Stripping Topsoil
  • Subbase/Excavation
  • Placing Pipe
  • Roadway Grading
  • Milling/Pulverizing
  • Trenching
  • Other

• Root Cause of Hit

  Select Miss Dig Not Called Digging before marked Markings disturbed Didn't hand dig in caution zone Not marked in a timely manner Inaccurate Markings No Markings in area Hit line while hand digging Other

  • Miss Dig Not Called
  • Digging before marked
  • Markings disturbed
  • Didn't hand dig in caution zone
  • Not marked in a timely manner
  • Inaccurate Markings
  • No Markings in area
  • Hit line while hand digging
  • Other

• Form completed by (sign)

  Sign

Utility Representative

• Utility name and representative name

• Did utility agree as to fault?

  Yes

  No

  N/A

• Utility Rep Signature

  Sign

• Photo of utility rep's license plate

  Media

• Notes: (List any additional info that will help with this claim).