Information
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Document No.
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Prepared by
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Date of the incident
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Date reported
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Location of incident
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Name of persons or contractor involved
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Brief description of the Event
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Type Operation
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Type of Service Damage
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Type of Service Found
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Type of Event
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Work Activity
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Service Strike/Near Miss Cause by
- Handtools
- Excavator
- Concrete Saw
- Hydrovac
- Drill
- Grundomat
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Weather Conditions
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Ground Conditions
- Hard
- Soft
- Rocky
- Sandy
- Tree Roots
- Combination
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Site Scanned by Who and What
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Walk Out Completed
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Services Marked Out
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Markouts as per Service Plans
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Locate & Markout Accurate
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Service Plans Onsite
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Service Plans Accurate
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All Services Clearly Marked/detailed/indicated on Service plans for the Operation
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CAR - Corridor Access Permit in place for Operation
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Close Approach Permit in-place and onsite for Operation
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Permit to Excavate in place and issued for Operation
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Close Approach Permit Current
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Has the Asset owner been notified of the Strike or Service found
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Photos of Service Damage or Service Found
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Name of person filing report and signature
