Title Page
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Ref Number
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Date of Investigation
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Investigation by
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Client or Contract Name
- Zzoomm
- Openreach
- Rural Fibre4U
- Grain Connect
- Telent IS
- Private
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Was any boby injured?
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Please list any injuries and complete the Accident book asap.
Utility Damage Evidence Investigation
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Incident Date and Time
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Project Number or Job Number
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Supervisor
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Type of Work
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Subcontractor Name or Team Number
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Incident Address
Utility Information (Identify Utility Damaged)
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Which Utility?
- Gas
- Water
- Electric
- BT
- Cable
- Sewer
- Other
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Shown on drawings?
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Add Photo
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Add Photo
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Pressure / Voltage
- LP
- MP
- IP
- HP
- LV
- HV
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Size of Utility
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Service or Main
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Where is the Utility
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Depth of Utility
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Add Photo
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Measured or Estimated
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What Caused the Damage
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Ground Conditions
Team Information
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Name
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Team Number and responsible persons name
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Service Length
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Qualifications
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Name
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Employee Number
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Service Length
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Qualifications
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Name
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Employee Number
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Service Length
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Qualifications
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Name
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Employee Number
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Service Length
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Qualifications
What Happened
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Explain in detail what happened and how it happened
Plan Information
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Were Plans on Site?
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Comment
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Comment
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Were Plans Clear and Accurate?
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Comment
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Comment
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Suitable Risk Assessment on site?
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Comment
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Comment
Location Equipment Information
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Was CAT Available?
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CAT Serial Number
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CAT Calibration Due
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Was CAT functioning Correctly
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Was Genny Available?
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Genny Serial Number
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Genny Calibration Due
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Was Genny Functioning Correctly
Survey- Prior and During Operations
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Was CAT survey completed prior to works commencing?
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Was CAT used in conjunction with Genny?
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Were plans available and used with CAT and Genny?
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Were all located utilities marked prior to excavation?
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Was the CAT used during excavation?
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What depth was the CAT used during excavation?
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Which operative completed the CAT/Genny Survey?
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What modes were utilised during CAT survey?
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During investigation did site manager confirm location of apparatus by conducting his own survey (what were the results)
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Date And Time
Operation/Excavation
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Comments must be made where applicable: PHOTOGRAPHS REQUIRED
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Was all underground plant located and marked by survey?
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Add Photo
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Comment
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Was plant located within 500mm of surface?
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Comment
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Was mechanical excavation used?
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Which operative was excavating?
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If mechanical plant was used, who was the operator?
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If hand excavation, what tools were used and by whom?
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Was all relevant PPE worn?
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Details of PPE
- Hard Hat
- Eye Protection
- Gloves
- FR / Arc Resistant Clothing / Coveralls
- Safety Boots
- Hearing Protection
- Hi-Vis
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Was the Utility Damage Avoidable?
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Reason
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Reason
Further Information
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Any further comments including previous damage history to the same location or different locations?
Action Already Taken- Corrective Action and Preventative Measures.
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Action
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Owner
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Date Required
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Completed
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Confirm Completed
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Action
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Owner
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Date Required
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Completed
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Confirm Completed
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Action
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Owner
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Date Required
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Completed
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Confirm Completed
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Action
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Owner
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Date Required
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Completed
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Confirm Completed
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Action
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Owner
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Date Required
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Completed
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Confirm Completed
Check List- The form must not be accepted without the following (list documents attached by reference)
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Utility plans attached
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Risk assessment attached
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Photographs of damaged utility
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Photographs of mark up
Signatures
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Team Leader/Supervisor
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Site/Team Manager
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Operation Manager
