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Utility Hit

Home > Accident/Incident Reporting and Information > Utility Hit

Utility Hit

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Job Classification*

Utility Hit Reporting Form Checklist

Report to your supervisor immediately; then, complete as much of the report as possible.

Project/Job Name & TEI Job Number:

Date of Hit:

MM slash DD slash YYYY

Approximate Time of Hit:

Was the facility owner a member of One-Call Center?

Yes

No

One Call Ticket Number:

File

Max. file size: 32 MB.

Crew Forman:

Immediate Supervisor:

Involved Parties:

Name and Title of Person Completing Form:

Who Owns the Utility?

Equipment that struck the utility:

(include the TEI equipment number)

Equipment Operator Name & Classification:

Location of Loss:

Address

Address City State / Province / Region

Right-of-way where event occurred:

Check appropriate boxes where applicable.

Public Property

Private Property

City Street

Private Land Owner

Interstate Highway

Private Business

Power/Transmission Line

Private Easement

Pipeline

Railroad

Dedicated Public Easement

Federal Land

County Road

Public - Other

State Highway

Data Not Collected

Unknown/Other

What marked utilities did you observe?

Gas

Electric

Telephone

Cable TV

Water

Sewer

Based on visual observation, did you see any other signs of any other unmarked utilities, such as:

Gas

Electric

Telephone

Cable TV

Water

Sewer

Was this a Re-Mark?

Yes

No

Date of Re-Mark Request:

Area of Re-Mark:

Did the utility hit occur inside the designated Re-Mark area?

Yes

No

Photos:

Photograph the entire proposed work area, including all locate marks.

I have photographed the entire sight prior to evaluation

Yes

No

File

Drop files here or

Max. file size: 32 MB.

I have photographed existing locate/markings

Yes

No

File

Drop files here or

Max. file size: 32 MB.

Photos taken AFTER the damage, but BEFORE the area was re-marked.

Yes

No

File

Drop files here or

Max. file size: 32 MB.

Damaged Facility Information:

Check appropriate boxes where applicable.

What type of facility operation was affected?

Cable Television

Telecom

Natural Gas

Liquid Pipeline

Water

Sanitary Sewer

Storm Sewers

Electric

Steam

Unknown/Other

Size of Utility:

Telecommunication: Copper

Yes

No

How many pairs?

Telecommunication: Fiberoptic

Yes

No

How many pairs?

Water/Sewer:

Lateral:

Water/Sewer:

Distribution Line Size:

Electrical:

3-Phase:

Electrical:

Megahertz or Volts Carried:

Gas:

Pipe Diameter:

Gas:

Lateral or distribution line:

What type of facility was affected?

Distribution

Gathering

Service/Drop

Transmission

Unknown/Other

Was the facility part of a joint trench?

Yes

No

Unknown

Describe the extent of damage to the utility:

(i.e. stretched, nicked, severed, etc.)

Was there an interruption of service?

Yes

No

To how many approximate homes and/or businesses?

How long was the interruption, if known?

Estimated cost of the repair, if known?

Name of the company that completed or will complete the repair:

Describe any collateral damage as a result of the hit:

(For example: two buildings damaged from gas explosion, sewage flooded five basements, restaurant shut down, etc.)

Other Information:

Were any employees injured?

If yes, complete the TEI injury/illness incident forms for each employee.

Yes

No

Were any bystanders or other contractors injured?

Yes

No

Name & Injury:

Witness Names (provide name and phone number if not a TEI employee)

Witness Names:

Witness Phone:

Witness Names:

Witness Phone:

Is there another witness?

Yes

No

Witness Names:

Witness Phone:

Other Comments:

Signature:

Please type your name:

Date:

MM slash DD slash YYYY

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Thompson Electric, Inc.
49 Northmoreland Avenue
Munroe Falls, Ohio 44262

Call: (330) 686-2300 Fax: (330) 686-2362

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