Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Job Info

  • Job #.

  • Location
  • One Call Reference No.

Damage Info

  • Date and time of damage

  • Damaged Utility

  • Photo identifying location

  • Photo of damage

  • Photo of markings in area

  • Additional photo if applicable

  • Sketch of damage

  • Describe damage and circumstances

  • Was damaged utility marked?

  • Was utility marked properly?

  • Crew members involved

  • Form completed by (sign)

Utility Representative

  • Utility name and representative name

  • Did utility agree as to fault?

  • Utility Rep Signature

  • Photo of utility rep's license plate

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.