Title Page
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Project Identifier
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Conducted on
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Prepared by
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Location of Damage
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Are you on the scene at the time of the incident?
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Date this incident was reported
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Pre-Incident Work Activity
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Incident Description
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Were locates called in? (Provide copy of locate ticket request)
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Locate Marking Condition
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Contractor Assigned to Project
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Contractor Contact Information
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Contractor Notification Date & Time
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Responsible Party
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How could this have been prevented?
