Utility Damage Report - Gold Shovel Standard



Utility Damage ReportInstructions: This report is to be completed by the jobsite foreman/supervisor & forwarded to management by the end of the next business day.DO NOT SPECULATE AS TO WHY THIS DAMAGE OCCURRED. DESCRIBE WHAT HAPPENED IN DETAIL ONLY.General InformationDate of damage _____ /_____ /____MM / DD / YYYYTime of Damage ____:____ FORMCHECKBOX AM FORMCHECKBOX PMPERSONNELAREA MANAGER:SUPERVISOR:FOREMAN:Address of damage FORMTEXT ?????CityState FORMTEXT ?????Zip FORMTEXT ?????Did you report the damage to…. date and timeManagement FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Name:Safety Coordinator FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Name:Customer FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Name:Facility Owner FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Name:Other FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Name:valid one call / locate ticket number prior to excavating? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, enter number:does the owner of the damaged facility participate in the one-call process? FORMCHECKBOX yes FORMCHECKBOX noType of work being done? (gas, electric, water, sewer, etc.)Work being done for what customer?Were there any injuries? FORMCHECKBOX yes FORMCHECKBOX no if yes, also complete an injury reportDid any emergency personnel respond to the damage / incident? FORMCHECKBOX yes FORMCHECKBOX no if yes, Identify: FORMTEXT ????? Was an evacuation necessary? FORMCHECKBOX Yes FORMCHECKBOX no if yes, explain: FORMTEXT ????? Who ordered? FORMTEXT ????? Was traffic stopped or detoured? FORMCHECKBOX yes FORMCHECKBOX no if yes, explain: FORMTEXT ????? Utility Damage Detailswas the utility marked?Name of utility company damaged: FORMCHECKBOX MarkedHow was it marked? FORMCHECKBOX Un-marked FORMCHECKBOX mis-markedhow far off were the marks? ___ ft ___ inches in what way was it mis-marked?DAMAGE LOCATION FORMCHECKBOX Undergrounddepth at damage ______ feet ________ inches FORMCHECKBOX Above ground Type of damage(cut, impact, pulled, fire, other etc.)did the damage occur within the tolerance zone of the location marks? FORMCHECKBOX Yes FORMCHECKBOX NoWas the damage done by non-mechanized hand tools? (shovels, probes, etc.) FORMCHECKBOX yes FORMCHECKBOX nohas the investigation determined if the damage occurred during the removal of strata? (existing roadway, sidewalk, hardscape) FORMCHECKBOX yes FORMCHECKBOX nowas the damage associated with a previous improper installation? FORMCHECKBOX yes FORMCHECKBOX noType of Utility (electrical, cable, gas, water, sewer, other, etc. Type of Service (main, service, other, unknown, etc.) Duration of service Interruption (hours / minutes)damaged utility:material type: (steel, plastic, etc.)pressure (psig/inches)size (diameter, voltage, pairs, etc.)Name & contact information of utility personnel who responded?Repair information – done by the utility companyHow many people responded?# of vehicles involved?Major equipment involved?Major materials involved?Additional remarks / comments about the type and extent of damageDamage caused by: specifically describe equipment which caused damage:(example, backhoe, shovel, jackhammer, etc.)Name of employee Operating equipment or tool that caused damage ____________________________________________________________________________________________site conditions and weather at the time of incident:Description of the incident. what happened? please be specific and include as many details as possible. Include such things as what you saw, heard, observed. attach additional sheets if necessary. also, use this section to identify and note any comments made by utility / locating personnel while at the scene. DO NOT SPECULATE AS TO WHY. DESCRIBE WHAT HAPPENED IN DETAIL ONLY. FORMTEXT ????? witness informationNameAddressPhone number FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Did you take a minimum of 24 pictures? FORMCHECKBOX Yes FORMCHECKBOX Noif no, explain why? FORMTEXT ?????Do Photos show the damage? FORMCHECKBOX Yes FORMCHECKBOX Noif no, explain why? FORMTEXT ?????Photos show depth of damage with a measuring device? FORMCHECKBOX Yes FORMCHECKBOX Noif no, explain why? FORMTEXT ?????Photos show mis-marked areas with a measuring device? FORMCHECKBOX Yes FORMCHECKBOX Noif no, explain why? FORMTEXT ?????Photos show date of damage? FORMCHECKBOX Yes FORMCHECKBOX Noif no, explain why? FORMTEXT ?????Did you get witness statements? FORMCHECKBOX Yes FORMCHECKBOX Noif no, explain why? FORMTEXT ????? down time detailsName and title of all crew members on site:All Equipment, Vehicles and trailers on site:Amount of time delay:did we assist in the repair in any way? FORMCHECKBOX Yes FORMCHECKBOX No If yes, explain: Report Preparerreport prepared by: (print name) FORMTEXT ?????job title: FORMTEXT ?????phone number: FORMTEXT ?????date prepared: FORMTEXT ?????preparer signature:SKETCH OF SITE AND DAMAGEprovide a detailed sketch of the area: To accurately describe the incident, please include the following: (1) direction of north (2) the underground utilities using solid lines; label by type (gas, water, phone, etc.)(3) location of incident using fixed distance landmarks (transformer, poles, peds, gas meter, etc.)(4) the location of the marks using dashed lines placed by utility/locator; label by type and color of marking)(5) the distance between the incident and the marks.(6) Closest Road/street or Direction to closest road/street(7) drawing needs to fit in the area below providedsolid lines for utilities, dashed lines for location marks, x for damage location, Indicate North by arrowWitness Statement Form(To be completed by the witness)Location of Incident: Date of Incident:Time of Incident:Your Name:Home Address:Phone:Your Company Name:Your Job Title:Your Supervisors NamePLEASE PRINT. Give a factual statement of YOUR actions & observations, preceding, during and following the occurrence. Use additional pages if needed.DO NOT SPECULATE WHY, DESCRIBE (IN DETAIL) WHAT HAPPENED ONLY.__________________________________________________________________________________________________Names of others with knowledge of occurrence:Signature:Date: ................
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