Damaged Utility Reporting Form
Customers Name
*
First Name
Last Name
Job Number
*
LINC20-0001 or LINR20-0001)
Address Where hit occurred
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Foreman's Name
*
First Name
Last Name
Employee who hit line
*
First Name
Last Name
Equipment/Tools that were being used when hit occurred.
*
Post Hole Diggers
Little Beaver
Skid Loader
Date of Hit
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Affected Utility (Select one or more)
*
Electric
Natural Gas
Cable
Phone
Water
Sewer
Other
Were facility marks visible in the area of excavation
*
Yes
No
Were facility marks accurate?
*
Yes
No
What were facilities marked with?
*
Flags & Paint
Flags
Paint
Do you have a signed waiver form from the customer to hand dig?
NO
YES
Were utility repairs completed while onsite allowing you to set all posts
NO
YES
Foreman's Comments
Who at AFC did you notify of the utility hit?
First Name
Last Name
Wide Shot Photo showing area of damage in reference to Locates
*
Wide shot #2
Close up photo showing measurement from marked utility to Damaged Utility
*
Close up #2
Are you a Project Manager or Superintendent?
Yes
No
Name of person who contacted 811
*
First Name
Last Name
Original Ticket Number
*
To be Filled out by Project Manager/Superintendent
Utility Hit Ticket Number
*
To be Filled out by Project Manager/Superintendent
Submit
Should be Empty: