Utility Damage Incident Report Form



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How to create a Utility Damage Incident Report? An easy way to start completing your report is to download this Utility Damage Incident Report Form now!

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




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