Buried Facility Incident Report Form

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"Locate Accurately, Dig Safely"  A Shared Responsibility.

This form has been designed to collect information on all types of buried facility "events" such as no locates, inaccurate locates, near misses, damages and any other pertinent information regarding utility locating, avoidance and protection.

**Note that all data gathered from this form is for informational purposes only**

Company
Individual
Position

Date of the Incident:                   Dig Ticket #               Start Date              Expiry Date

mm/dd/year                                 

Was the Facility  located?   Yes    No

Were the facility marks visible in the area of excavation?    Yes No

Enter the location of the incident, including cross streets, city and state or county:

Describe what was found (exposed) and closest distance (inches) from the facility to the marks.

Select which facilities were effected:

Telephone           Gas                    Electric               Water                   Traffic Signal         
Sewer                  Street Light       Cable TV            None                    Other

Is the facility owner a member of USA North?:    Yes  No

Select the type of work being performed:

Telephone         Gas                     Electric              Water                    Traffic Signal

Sewer                Street Light        Cable TV           Landscaping        Other

Storm Drain       Pothole / Soft Dig                             Site Development             

Did the excavator incur downtime?    Yes No

What is the estimated cost of this downtime?   $ 

Was there damage to the facility?    Yes No NA

In your opinion, what was the root cause of the incident?

One call center error        Insufficient Marking or Locating         Abandoned Facility     

Facility was not located or marked            Other                    

Provide any additional information regarding this incident?        In you opinion, what could have prevented this incident?

                          

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Revised: 05/21/08