HTML Preview Damage Incident page number 1.
UTILITY DAMAGE INCIDENT REPORT
FORM062-UTILITY DAMAGE INCIDENT REPORT.DOCX Rev 08/11 Page 1 of 4
General Information
Project: Project No.:
Contractor:
Contractor POC for This Incident Cell #:
Utility Owner:
Date/Time Damaged: Date/Time 1
st
Identified:
General Location of Work Area:
Address Where Incident Occurred:
Damage 1
st
Reported by:
Describe Incident & Damage to Utility Asset:
(attach photos & supplemental information)
Describe Collateral Damage to Equipment or Property:
(attach photos & supplemental information)
Did Personal Injuries Result for this Incident?
Yes No
(If yes, complete & Attach Accident Incident Report
Utility Interaction
Date/Time Utility Notified: Name Contractor Notifier:
Name/Title Utility POC: Cell/Telephone #:
Summarize Utility Initial Response:
Date/Time Utility 1
st
on Site:
Did Utility Repair Damage on Initial Visit? Yes No
(If No, complete attached Utility Contact Log)
Date/Time Utility Completed Repairs:
Does Utility Require Special Work Methods? Yes No
(If Yes, attach agreed requirements)