Accurate site and contractor information is critical for emergency response coordination and regulatory documentation. Complete all mandatory fields with precise data.
Project Name
Project Identification Number
Site Physical Address
GPS Coordinates (Latitude, Longitude)
Contractor Company Legal Name
Contractor License/Registration Number
Site Superintendent Full Name
Superintendent Direct Contact Number
Exact Date and Time of Incident
Time of Report Submission
Weather Conditions at Time of Incident
Clear
Partly Cloudy
Overcast
Light Rain
Heavy Rain
Snow
Fog
High Winds
Extreme Heat
Extreme Cold
Type of Excavation Work Being Performed
Trenching
Foundation Digging
Horizontal Directional Drilling
Potholing/Vacuum Excavation
Demolition
Grading/Landscaping
Piling
Other
Equipment Involved in Incident
Excavator
Backhoe
Trencher
Bulldozer
Drill Rig
Pneumatic Hammer
Hand Tools
Other
Number of Workers Present on Site at Time of Incident
Excavation Depth at Incident Location (meters)
Excavation Method Classification
Mechanical Excavation
Manual Hand Dig
Hydro/Vacuum Excavation
Combination Method
Precise identification of the impacted utility and accurate assessment of damage severity are essential for determining appropriate emergency response protocols and resource allocation.
Utility Type That Was Struck
Natural Gas Distribution
Electric Power Line
Potable Water Main
Sanitary Sewer
Storm Drain
Telecommunications Fiber
Petroleum Product Pipeline
Steam Distribution
Other
Is gas leak audible or visible?
Is power line still energized?
Is water flow under pressure?
Was the utility properly identified and marked before excavation began?
Source of Utility Location Information
One-Call Center/Notification Service
Private Locator Service
As-Built Drawings
Previous Survey
Physical Site Markings
Other
Explain why utility was not identified prior to work:
Approximate Depth of Struck Utility Below Ground Surface (meters)
Accuracy of Pre-Excavation Utility Location Markings
Highly Inaccurate
Moderately Inaccurate
Slightly Inaccurate
Accurate
Highly Accurate
Type of Physical Damage Sustained
Complete Severance/Cut
Partial Piercing/Puncture
Dent/Deformation
Crack/Fracture
Multiple Damage Points
Unknown Extent
Detailed Description of Damage Extent and Observed Conditions
Upload Photographic Evidence of Damage Site (Multiple Angles Required)
Is there active release of utility substance (gas, water, etc.)?
Describe released substance characteristics and behavior:
Estimated Flow Rate or Volume of Release (if applicable)
Utility Operating Pressure at Time of Strike (if applicable, in bar/psi)
Approximate Area of Ground Contamination or Affected Zone (square meters)
Status of Utility Markings Visibility at Exact Strike Location
Clearly Visible and Accurate
Faded/Partially Visible,Obscured by Equipment/Materials,Not Present,Incorrectly Located
Explain what obscured the markings:
Explain absence of markings:
Describe how markings were incorrect:
Document all immediate life-safety actions and site control measures implemented within the first 15 minutes of incident discovery.
Immediate Actions Taken Upon Discovery of Utility Strike
Was immediate evacuation of site personnel initiated?
Evacuation Radius Established (meters)
Total Number of Personnel Evacuated from Site
Was public evacuation of adjacent areas required?
Describe affected public areas and notification methods used:
Were Emergency Services (Fire, Medical, Police) Contacted?
List agencies contacted, contact times, and response status:
Is site perimeter secured with barriers and warning signage?
Upload photo of secured perimeter and signage
Was First Aid Administered to Any Personnel?
Number of Personnel Requiring First Aid
Were Any Injuries Sustained?
Injured Personnel Details
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Were Fire Suppression Systems or Equipment Activated?
Describe fire suppression actions and equipment used:
Were Ventilation Measures Implemented (for gas leaks)?
Describe ventilation methods and equipment:
Was Hazardous Atmosphere Detected Using Gas Monitor?
Report gas monitor readings and locations tested:
Were Adjacent Utilities Isolated or Shut Down as Precaution?
List isolated utilities and shutdown procedures:
Document all communications with utility owner/operator and coordinate repair activities to minimize service disruption and ensure permanent restoration.
Has the Utility Owner/Operator Been Officially Notified?
Official Notification Time
Explain delay in notification and immediate steps being taken:
Utility Company Contact Person Name and Title
Utility Company Contact Number
Estimated Time for Utility Company Response (minutes)
Has Utility Company Repair Crew Arrived on Site?
Time of Repair Crew Arrival
Have Temporary Service Restoration Measures Been Implemented?
Describe temporary measures (bypass, rerouting, etc.):
Estimated Duration for Permanent Repair (hours)
Extent of Service Disruption
No Service Disruption
Temporary Interruption (< 2 hours)
Short-term Outage (2-24 hours)
Extended Outage (1-7 days)
Prolonged Outage (> 7 days)
Parties Affected by Service Disruption
Residential Customers
Commercial Businesses
Industrial Facilities
Critical Infrastructure (hospital, school)
Transportation Systems
None
Proposed Repair Methodology
Direct Pipe Replacement
Pipe Patching/Clamping
Directional Drilling Bypass
Open Trench Repair
Evaluation Pending
Is Cost Estimate for Repair Available?
Estimated Repair Cost
Additional Coordination Notes with Utility Company
Final authorization requires certified professional assessment and regulatory clearance before normal site operations may resume. All signatures must be captured in real-time with timestamp.
Is Qualified Engineer Assessment Required for Site Structural Integrity?
Engineer Full Name and Professional Credential
Engineer Site Inspection Time
Engineer Assessment of Adjacent Ground Stability
Structurally Sound - No Concerns
Minor Concerns - Monitoring Required,Moderate Concerns - Reinforcement Needed,Severe Concerns - Immediate Stabilization Required,Assessment Pending
Has Regulatory Safety Inspector Been Notified?
Inspector Name and Authority/Agency
Inspector Site Attendance Time
Has Formal Incident Report Been Filed with Regulatory Authority?
Has Site Received Official Safety Clearance for Re-Entry?
Specify clearance conditions and any restrictions:
Is Work Resumption Authorized in Affected Area?
Specify remaining hazards and required corrective actions:
Preventive Measures Implemented to Prevent Recurrence
Enhanced Utility Locating
Hand Digging Zone Expansion
Real-Time Monitoring
Additional Supervision
Revised Excavation Plan
Improved Barrier Protection
Enhanced Training
None Yet
Upload Additional Supporting Documentation (maps, drawings, correspondence)
Site Superintendent Digital Signature - Verifying Accuracy of Report
Qualified Engineer Digital Signature - Structural Safety Approval
Safety Inspector Digital Signature - Regulatory Clearance
Final Authorization Timestamp
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