Information

  • Contractor

  • Foreman:

  • Conducted on

  • Prepared by

  • Location
  • Crew Members:

  • Client

Utility Damage Investigation

Information

  • Damage Date:

  • What utility line was damaged?

  • Was the Emergency One Call System Notified?

  • Original One Call #

  • Damage One Call #

  • Was 911 Called?

  • Did the emergency responders arive on the jobsite?

  • Utility Company Contacted

  • Name of Utility Representative

  • Utility Representative Phone Number

Damage Investigation

  • Damage Caused By:

  • Damage to:

  • Line Characteristics:

  • Number of lines in pair:

  • Depth of utility cover:

  • Distance from gas line:

  • Distance from markings:

  • Line Characteristics:

  • Depth of Cover:

  • Distance from gas line:

  • Distance from markings:

  • Line Characteristics:

  • Line Voltage:

  • Depth of Cover:

  • Distance from gas line:

  • DIstance from markings:

  • Material Type:

  • Line Pressure:

  • Line Size:

  • Depth of Utility Cover:

  • Distance from nearest markings:

  • Distance from nearest gas utility line or curb valve:

  • Distance from nearest sidewalk or street:

  • Distance from nearest shut off valve:

  • If applicable, did the crew follow proper Emergency Respose Protol (911 notification), Contact Gas Company Personnel, protect life, evacuate the work area, stop all digging, remain upwind, eliminate ll ignition sources, move people away from the area, and never enter into the excavation without proper Stop Work Authority program implementation, and PPE?

  • What Could the crew have done differently:

  • Were Pre Job Pictures taken?

  • Describe events leading up to damage:

  • What conditions of the work area contributed to the damages?

  • What job factors contributed to the damage?

  • What Actions or Indirect Causes and Root Causes lead to the damages?

  • Recommended Corrective Actions for Prevention:

  • Pictures of Damage (Take at least 10 pictures from all angles)

  • Provide a sketch of the damage location:

  • Signature:

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.