Information
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Project Name & Number:
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Conducted on
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Prepared by
Job Info
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Project Number:
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Road/Street Name:
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Town:
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Nearest address & stationing to hit
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Nearest Intersection to hit
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What side of road was utility hit on
Utility Location Information
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Was the Utility Notification Center (811) contacted prior to digging?
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Ticket Number:
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Call In Date/Time
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Restake Date/Time
Damage Information
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Date and time of damage
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Utility Damaged
- Gas
- Phone
- Underground Electric
- Overhead Electric
- Cable
- DSL
- Water
- Sewer
- storm/culverts
- Irrigation
- Fiber
- Unknown
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Utility Owner
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Photo identifying location
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Photo of damage
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Photo of markings in area
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Additional photo if applicable
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Was damaged utility marked?
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Was utility marked properly?
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How was the utility marked
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Was the utility potholed?
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Describe damage and circumstances
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Name of Supervisor:
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Operator Involved (if applicable)
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Was the supervisor onsite when the incident occurred?
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Equipment Involved
- Backhoe/Excavator
- Dozer
- Grader
- Loader/Skidsteer
- Scraper
- Mill/Pulverizer
- Trencher
- Hand Tools i.e. shovel, probe, etc.
- Truck (bed)
- Truck (equipment transport)
- Other
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Equipment Number (If Applicable)
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Type of Work Being Performed
- Removal of culvert, curb, etc
- Removal of Trees, Stumps
- Placing Silt Fence
- Stripping Topsoil
- Sub-base/Excavation
- Placing Pipe
- Roadway Grading
- Milling/Pulverizing
- Excavating
- Other
- Installation of culvert, curb, inlet, etc
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Root Cause of Hit
- 811 Not Called
- Digging before marked
- Markings disturbed
- Didn't hand dig in caution zone
- Not marked in a timely manner
- Inaccurate Markings
- No Markings in area
- Other
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Comments:
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Form completed by (sign)
Utility Representative (If Applicable)
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Utility name and representative name
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Did utility agree as to fault?
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Utility Rep Signature
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Photo of utility rep's license plate
