Utility Damage Report
IV Network Designs Inc — Field Incident Documentation
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Job & Location Info
Company / Contractor Name
Project / Job Number
*
Required
Client
Damage Address / Location
*
Required
Print Reference
Depth at Strike
■
One-Call / Locate Ticket
Ticket Number
*
Required
Ticket Date
Utility Mark Status
Marked
Unmarked
Mismarked
N/A
Distance from Locate Marks
Locator Company
Locator Name
■
Strike / Damage Details
Utility Type
*
Gas
Electric
Water
Sewer
Telecom
Fiber
Storm
Other
Utility Owner
Pipe / Line Size
Material
Severity Level
*
Minor
Moderate
Major
Critical
Equipment Used at Time of Strike
Damage Description
*
Required
⚒ Excavation for Repair
Did your crew excavate / expose the utility for faster repair?
Yes — We excavated
No — Not allowed
No — Not needed
Utility co. handled
Excavation Details
Reason Not Allowed
Excavating for repair can significantly reduce damage costs and repair time.
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Response & Notifications
Actions Taken
Called 911
Evacuated
Utility called
Secured area
Work stopped
One-Call notified
Any Injuries?
No
Yes
Injury Details
Utility Company Notified
Time Notified
Contact Person at Utility
Contact Phone
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Weather & Site Conditions
Weather
Clear
Cloudy
Rain
Wind
Ground Conditions
Dry
Wet
Muddy
Frozen
Rocky
Soil Type
■
Crew Information
Foreman
*
Required
Operator
Superintendent
Witnesses
■
Photos
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Signature
Clear
■
Additional Notes
Clear
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