Utility Damage Report

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Job Info

• Job # (or use slider below)

• Job # (or fill in above

• Town

• Nearest address

• Dig Safe num

Damage Info

• Date and time of damage

  Date

• Damaged Utility

  Select Gas Electric Cablevision Telephone Water Sewer Drain Sprinkler Dog Fence Other

  • Gas
  • Electric
  • Cablevision
  • Telephone
  • Water
  • Sewer
  • Drain
  • Sprinkler
  • Dog Fence
  • Other

• Photo identifying location

  Media

• Photo of damage

  Media

• Photo of markings in area

  Media

• Additional photo if applicable

  Media

• Sketch of damage

  Drawing

• Describe damage and circumstances

• Was damaged utility marked?

  Yes

  No

  N/A

• Was utility marked properly?

  Yes

  No

  N/A

• Crew members involved

• Form completed by (sign)

  Sign

Utility Representative

• Utility name and representative name

• Did utility agree as to fault?

  Yes

  No

  N/A

• Utility Rep Signature

  Sign

• Photo of utility rep's license plate

  Media