Damage Prevention Reporting Information Provide the following information as completely as possible. *Required Field
PART A - WHO IS SUBMITTING THIS INFORMATION
*Who is providing this information? Excavator Locator Facility Owner Property Owner Other  (explain)	*Name of the person providing the information: (Use this format: John Doe/XYZ Company/123-456-7890)

PART B - DATE AND LOCATION OF THE EVENT
*Location of the excavation and/or damage (Include city and county)	*Date that damage or downtime occurred: (Use this format: mm/dd/yyyy)

PART C - AFFECTED FACILITY INFORMATION
*What type of facility operation was affected?			What type of facility was affected?
Telephone Gas Electric	Water Sewer Steam	Cable TV Petroleum  Pipeline Other	Transmission Distribution Service Other
Is the facility owner a member of a one-call?   Yes   No

PART D - EXCAVATION INFORMATION
Type of Excavator:			Type of Excavation Equipment:
Contractor Developer Utility Municipality County	State Railroad Occupant Farmer Unknown	Other	Explosives Hand Tools Mechanized Equipment Type of mech equip:

Type of Work Performed:
Sewer Gas Water Electric Storm Drain Steam TV Cable Road Work Telecommunications Waterway Improvement	Petroleum Pipeline Curb/Sidewalk Transit Authority Railroad  Maintenance Pole Fencing Street Light Drainage Agriculture Traffic Signal/Sign	Bldg. Demolition Bldg. Construction Site Development Landscaping Driveway Lot Grade Other

PART E - NOTIFICATION
*Did the excavator call the one-call notification center? Yes  No	If Yes, provide the one-call notification ticket number. Ticket Number:

PART F - LOCATING AND MARKING
Type of locator: Utility Owner      Contract Locator      Other
Were facility marks visible in the area of excavation? Yes  No	Were the facilities marked correctly? Yes  No

PART G - DESCRIPTION OF EXCAVATOR DOWNTIME
*Did the excavator incur downtime? Yes  No If yes, how much time?	Estimated cost of the downtime: $0-$5,000 $5,000-$25,000 over $25,000 Unknown

PART H - DESCRIPTION OF DAMAGE
*Was there damage to the facility? Yes   No Did the damage cause an interruption of service? Yes   No If yes, duration of the outage: Approximately how many customers were affected:	Estimated cost of the damage and repair/restoration: $0-$5,000 $5,000-$25,000 over $25,000 Unknown Number of people injured:  Number of fatalities:

PART I - DESCRIPTION OF THE ROOT CAUSE
What was the root cause of the damage, downtime, or near-miss?
Facility marking or location not sufficient Facility was not located or marked Facility could not be located Abandoned facility Incorrect facility records/maps Wrong information provided Deteriorated facility	No notification made to the one-call      center Notification made to the one-call      center but not sufficient Excavation practices not sufficient Previous damage One-call notification center error Other

PART J - ADDITIONAL INFORMATION

Provide additional written explanation:

In your opinion, what could have prevented this event?