Andy Thelen

Underground Facility Incident Report

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Information

Document No.
Audit Title
Client / Site
Conducted on
Prepared by
Location
Personnel

Date and Time of Incident
Date and Time Owner was Notified
Date and Time Damage was Repaired
Incident Location
Job # / Description
MISSDIG Ticket #
Type of Facility
- Telephone
- Gas
- Electric
- CATV
- Water
- Sewer
- Storm Drain
- Other
Who Owns The Facility?
Was The Facility Clearly Marked?
Please Insert Photos here of the area. Be sure to take clear photos with established measurements.
Description of Facility ( Size,Type,Material,Pressure,Etc)
Please insert photos of damage here.
Additional Comments
Report Prepared By

Andy Thelen

Underground Facility Incident Report

Use this Template

Print as PDF

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.