Title Page
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Client / Project Name / Number
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Document No.
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Location of Incident:
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Date and time of Incident:
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Prepared by
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Right of Way where event occurred:
- City Street
- County Road
- State Highway
- Interstate Highway
- Private Buisiness
- Private Land Owner
- Public Utility
- Railroad
- Federal Land
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Affected Facility Information:
- Cable TV
- Fiber
- Electric
- Gas
- Sanitary Sewer
- Pipeline
- Phone
- Water
- Unknown
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Type of work performed:
- Drainage Ditch/Culvert
- Grading
- Road Work
- Storm Drain
- Water Line
- Sanitary Sewer
- Site Development
- Curb / Sidewalk
- Waterway Improvement
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Type of Equipment:
- Backhoe
- Excavator
- Grader / Scraper
- Loader
- Dozer
- Boring
- Hand Tools
- Probing Device
- Trencher
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Equipment Number:
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Was One-Call Center notified?
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If yes, please provide ticket number:
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Was the facility marked prior to the damage?
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What type of marks were present:
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Were facility marks visible in the area of construction?
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Were facilities marked correctly?
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Who marked the facility?
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Locators Name:
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Was there damage to the facility?
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What happened?
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Did incident cause interruption of service?
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If yes, duration of interruption:
- Unknown
- Less than 1 Hour
- 1-2 Hours
- 2-4 Hours
- 4-8 Hours
- 8-12 Hours
- 12-24 Hours
- 1-2 Days
- 2-3 Days
- More than 3 Days
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Were photos taken of damage?
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If not, please take photos now
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Did emergency services (i.e. fire department, police, etc.) respond?
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Was evacuation necessary?
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Was traffic stopped or detoured?
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Was anyone injured?
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Who:
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Was equipment damaged?
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If so, equipment number
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Root Cause of incident
- No notofication made to the one-call center
- Wrong information provided to one-call center
- Locating practices insufficient
- Facility could not be found or located
- Facility was not located or marked
- Abandoned facility
- Deteriorated facility
- No pre-task plan prior to excavation
- Failure to maintain clearance
- Failure to maintain marks
- Failure to support exposed facility
- Failure to use hand tools where required
- Failure to pothole
- Improper backfilling practice
- Previous damage
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Additional Comments:
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Submitted by:
