Page 1: Initial questions
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Conducted on
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Prepared by
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Location
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PN
Page 2: Main checklist
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Sub-Contractor
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Site Ganger
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Operatives involved
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Nature of Works
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Has a SSRA been completed
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Description of Events/Actions Leading up to Strike
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Immediate Action Taken Following the Strike
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Strike Resulted in Injury
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Utility Affected
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Reported to Utility - Referenced Number Required
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Surface Type
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Depth of Service
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Marker tape/Tiles/Mesh Present
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Utility Plans on Site
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Utility Noted on Plans
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Calibration Dates of Cat & Genny
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Services Clearly Marked Above Ground
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Damage Caused by Mechanical Excavation within 500mm of a Known Service
