Accurate location and identification details are critical for emergency response coordination and liability assessment. Provide precise information to expedite utility provider and municipal authority dispatch.
Exact Date and Time of Incident
GPS Coordinates (Latitude, Longitude)
Site Street Address
Nearest Landmark or Intersection
Site Access Restrictions or Hazards
Contractor Company Legal Name
Contractor License/Registration Number
Was Excavation Permit Valid and On-Site?
Excavation Permit Number
Permit Issuing Authority
Site Manager Full Name
Site Manager Role/Title
Site Manager Direct Contact Phone
Site Manager Email Address
Number of Workers Present on Site at Time of Incident
Primary Excavation Equipment Involved
Type of Excavation Work Being Performed
New Construction
Maintenance/Repair
Demolition
Utility Installation
Roadworks
Other
Weather Conditions at Time of Incident
Clear/Sunny
Overcast
Light Rain
Heavy Rain
Snow/Ice
Fog
High Winds
Visibility Conditions
Daylight - Good
Daylight - Poor
Dusk/Dawn
Dark - Artificial Lighting
Dark - Limited Lighting
Soil Conditions
Dry/Stable
Wet/Muddy
Sandy/Unstable
Rocky/Hard
Frozen
Previously Disturbed
Detailed utility identification and damage assessment enables appropriate emergency response and repair planning. Document all observable characteristics and potential secondary hazards.
Utility Type(s) Contacted (Select all that apply)
Natural Gas
Electric Power
Potable Water
Sanitary Sewer
Storm Drain
Telecommunications
Fiber Optic
Petroleum Product
Steam
Other
Utility Color Code or Surface Markings Observed
Planned/Recorded Utility Depth (meters)
Actual Depth at Strike Point (meters)
Utility Material Composition
Steel
Cast Iron
PVC/Plastic
Copper
Concrete
Clay Tile
Unknown
Other
Utility Diameter/Size Specification
Type of Contact/Incident
Direct Strike/Penetration
Scrape/Abraision
Crush/Compression
Pull/Displacement
Unknown
Detailed Description of Physical Damage
Damage Length (meters)
Damage Penetration Depth (millimeters)
Operating Pressure or Voltage Rating
Is the Utility Currently Operational?
Damage Assessment Matrix
Structural Integrity Loss | |
Leakage/Electrical Hazard | |
Repair Complexity | |
Service Disruption Impact | |
Environmental Risk |
Immediate Leak, Rupture, or Electrical Arc Observed?
Fire or Explosion Risk Assessment - Is there imminent danger?
Environmental Contamination Risk
Photograph(s) of Damage Site - Upload multiple angles
Video Documentation of Damage and Surrounding Area
Witness Statements and Observations
Document all immediate life-safety actions and site control measures implemented within the first critical minutes. This information is essential for evaluating response effectiveness and identifying additional hazard mitigation needs.
Was Site Immediately Evacuated?
Total Number of Personnel Evacuated
Were Warning Signs and Physical Barriers Erected?
Perimeter Isolation Distance Established (meters)
Were Affected Utilities Successfully Shut Off or Isolated?
Shut-Off Location Description
Time Shut-Off Completed
Name of Person Who Performed Shut-Off
Was Isolation Verified with Detection Equipment?
Ventilation or Atmospheric Monitoring Measures Implemented
Emergency Services Contacted (Select all applicable)
Fire Department
Emergency Medical Services
Police/Law Enforcement
Hazmat Team
None
Time Emergency Services Notified
Any Injuries Sustained?
First Aid Administered On-Site?
Medical Attention Required Beyond First Aid?
Property Damage Beyond the Utility Itself?
Maintain a chronological log of all external agency notifications and dispatch confirmations. This creates an audit trail for response time analysis and contractual service level compliance verification.
Utility Provider Emergency Line Contacted?
Provider Emergency Contact Person Name
Provider Contact Phone Number
Time Provider Notified
Provider Ticket/Reference Number
Estimated Provider Crew Arrival Time
Municipal Authorities Notified (Select all applicable)
Public Works Department
Transportation Authority
Environmental Agency
Building Inspector
None
Municipal Authority Contact Person
Time Municipal Authority Notified
Third-Party Repair Crew Dispatched?
Repair Crew Contact Person
Repair Crew Estimated Arrival
Specialized Equipment Required for Repair
Vacuum Excavation Truck
Hydraulic Excavator
Crane/Lifting Equipment
Pressure Testing Equipment
Welding Equipment
Traffic Control Devices
Other
Traffic Control Measures Implemented?
Public Safety Notifications Issued?
Estimated Repair Duration
Preliminary Repair Cost Estimate
Is Road or Area Closure Required?
Coordination Meeting Scheduled with All Stakeholders?
Final authorization and compliance verification ensures all procedural requirements are met and appropriate escalation has occurred. This section formalizes accountability and triggers post-incident review processes.
Incident Severity Classification
Level 1 - Minor (No injury, minimal damage)
Level 2 - Moderate (Minor injury, service disruption)
Level 3 - Major (Hospitalization, significant damage)
Level 4 - Critical (Fatality, catastrophic failure)
Does This Incident Require Formal Investigation?
Preliminary Root Cause Category
Failure to Locate/Identify
Excavation Equipment Operator Error
Incorrect Permit Information
Inadequate Site Supervision
Marked Utility Depth Inaccurate
Unmarked Utility
Other
Immediate Corrective Actions Already Implemented
Have All Required Parties Been Notified?
Documentation Completeness Verification
Photos Uploaded
Witness Statements Recorded
Detection Readings Logged
Notifications Documented
Maps/Sketches Attached
Overall Emergency Response Effectiveness (1=Poor, 5=Excellent)
Site Superintendent Full Name
Superintendent Review Date and Time
Site Superintendent Digital Signature
Safety/Compliance Officer Full Name
Safety Officer Review Date and Time
Safety Officer Digital Signature
Insurance Provider Notified?
Regulatory Reporting Required?
Media or Public Inquiry Management Required?
Lessons Learned Documentation Required?
Follow-Up Action Items
Action Description | Responsible Person | Target Completion Date | Status | |
|---|---|---|---|---|
Additional Comments or Recommendations