Incident Report Damage InformationName (Investigator)(Required)Original Locate TechnicianDirect Supervisor(Required)Please ChooseBrian SloneBrogan KennedyChuck Van EttenChris BarrDanny PrattDavid LutzEric BaileyGarrett BethelIan PowisJason GondekJayme WilcoxJohn JacksonJohn SurvantJoshua VeatchMatt HilbertNunci SchumacherPatrick ShepherdPhil FranklinRichard ChozinskiStephanie MarshTammy Hoskinson-WardWilliam HubbardThis field is hidden when viewing the formType of Incident? Please check all that apply(Required) Employee or Sub-Contractor Injury Equipment Damage Environmental Near Miss Good Catch Other Party Injury Security Utility Strike Other Describe "Other" Incident(Required)NL Customer(Required)Please SelectAES INAES OHAvon Community Schools FiberBloomington Digital Underground FiberBrightSpeed ALBrightSpeed IABrightSpeed ILBrightSpeed INBrightSpeed MIBrightSpeed MNBrightSpeed MOBrightSpeed OHBrightSpeed WICity of Columbus (OH) FiberCommunity Health Networks FiberDorel Juvenile FiberDuke Energy FiberEDP RenewablesEndeavorEverstream CHIEverstream ILEverstream INEverstream MISegra (Everstream MO)Everstream NorthEverstream OHEverstream WIGreat Plains ILGreat Plains INHamilton SE Schools FiberHendricks County Government FiberHorizonIntelligent Fiber Network (IFN)Indiana Railroad FiberInfinityIUIUPUILightstreamLigtelLumen ILLumen INLumen WIMVL OHMiso Energy FiberMonon TelephoneMonroe County FiberOther (Explain Below)SmithvilleSt Vincent FiberSurf ILSurf INSurf MITown of MonroviaTown of PlainfieldTrinsic FiberTurnkey ILTurnkey INTurnkey OHWashington Twp FiberWestfield FiberWesthaven Estates SewerWIN Fiber ILWIN Fiber MNWIN Fiber WIZayo INZayo MNNL Customer Other(Required)Mobile Damage Claim #Original Ticket NumberDamage Ticket NumberAddress of Incident(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State This field is hidden when viewing the formCity & State where incident occurredDate of Incident(Required) MM slash DD slash YYYY Date of Investigation(Required) MM slash DD slash YYYY Time of Incident Hours : Minutes AM PM AM/PM Detailed description of place/location of event(Required)Example: Contractor struck the secondary service to 8138 Winterset Cir on the east side of the house approximately 15 ft out from the house.Direct CauseContributing Factors(Required) Excavator Utility Owner Northern Lights Excavator Contributing Factor(Required) No notification made to One Call Center/811 Excavator dug outside area described on ticket Excavator dug prior to valid start date/time Excavator dug after valid ticket expired Excavator provided incorrect notification information Excavator dug prior to verifying marks by test-hole (pothole) Excavator failed to maintain clearance after verifying marks Excavator failed to protect/shore/support facilities Improper backfilling practices Marks faded or not maintained Not Listed (explain below) Other Excavator Contributing Factor Explained(Required)Northern Lights Contributing Factor(Required) Did not pull prints No documentation Unlocatable Facility Signal bled off target Did not identify utility Missed or misread prints Incorrect facility records/maps Did not mark scope of ticket Improper locating procedures Unmarked: Ticket Late Unmarked: Closed Out Wrong Unmarked: Areas or utilities not marked at all Mismarked: Incorrect locate markings (e.g., outside tolerance zone, wrong utility path) Equipment Misuse: Errors caused by improper use or malfunction of locating equipment. Not Listed (explain below) Other Northern Lights Contributing Factor Explained(Required)Utility Owner Contributing Factor(Required) Bled off Unlocatable facility Utility not coded on ticket Ticket not assigned to Northern Lights Turned over back to utility Prints incorrect / not updated Facility currently not in service Marked off measurements / field notes Not Listed (explain below) Other Utility Owner Contributing Factor Explained(Required)This field is hidden when viewing the formNorthern Lights At-Fault? Indicators Suggest Possible Locate Error No Indicators of Locate Error Information Not Available / Not Applicable Still Under Review Yes No N/A Undetermined At This Time This field is hidden when viewing the formLocating Root Cause Mismarked: Incorrect locate markings (e.g., outside tolerance zone, wrong utility path) Unmarked: Ticket Late Unmarked: Closed Out Wrong Unmarked: Areas or utilities not marked at all Unlocatable Facility Incorrect facility records/maps Equipment Misuse: Errors caused by improper use or malfunction of locating equipment. Root Cause Not Listed (explain below) This field is hidden when viewing the formRoot Cause ExplainedThis field is hidden when viewing the formLocating Root Cause Mismarked: Incorrect locate markings (e.g., outside tolerance zone, wrong utility path) Unmarked: Ticket Late Unmarked: Closed Out Wrong Unmarked: Areas or utilities not marked at all Unlocatable Facility Incorrect facility records/maps Equipment Misuse: Errors caused by improper use or malfunction of locating equipment. Root Cause Not Listed (explain below) This field is hidden when viewing the formRoot Cause ExplainedThis field is hidden when viewing the formExcavation Root Cause No notification made to One Call Center/811 Excavator dug outside area described on ticket Excavator dug prior to valid start date/time Excavator dug after valid ticket expired Excavator provided incorrect notification information Excavator dug prior to verifying marks by test-hole (pothole) Excavator failed to maintain clearance after verifying marks Excavator failed to protect/shore/support facilities Improper backfilling practices Marks faded or not maintained Improper excavation practice not listed above This field is hidden when viewing the formImproper excavation practice explainedScene DocumentationFacility Type(Required)Please ChooseBuried Copper CableBuried Fiber CableUtility Damaged By(Required)Hand tools, shovel, mechanical equipment, etc. Activity Causing Damage(Required)Type of Work Being DoneWere marks visible at the time of excavation?(Required) No Yes Describe condition of marks(Required)Please ChooseClear and Visible – The marks are easily identifiable and clearly distinguishable.Faded but Legible – The marks are somewhat worn but still recognizable and usable.Partially Obstructed – The marks are covered by debris, dirt, or other obstructions but are still partially visible.Completely Obscured – The marks are fully covered or erased, making them unidentifiable.No Marks Found – No visible marks were present in the excavation area.Other (Specify) – Allows for custom input if the condition does not fit the predefined options.Describe condition of marks:(Required)Was the damage inside the state specified tolerance zone?(Required) No Yes N/A Distance from Nearest Mark to Damage(Required)Measurement (in inches/feet)Measurement Photo Attached(Required) No Yes Detailed Incident InformationBusiness or Individual Who Caused Damage(Required)Please list Employee's names, Contractor names or other parties' names that were involved in the incident (First and Last Names)(Required)Describe what occurred using facts only (who, what, when, where, how)(Required)Provide a chronological sequence of events: Who was involved? What happened? When and where did it happen? How and why did the incident occur? Involvement of materials, equipment, or vehicles before, during, and after the incident.This field is hidden when viewing the formWhat did you gather for further investigation and/or reporting? Please check all that apply.(Required) Pictures (Pre-Dig, Post-Dig, Damage, Vehicle, License Plates, Equipment, PPE, etc.) Witness Statements Police Report Insurance Auto Claim Report Salvaged Damaged or Defective Equipment JHA and Associated Job Paperwork DVIR if Applicable to the Type of Incident PPE Worn One Call Ticket # Other What did you gather for further investigation and/or reporting? Please check all that apply.(Required) Pictures (Pre-Dig, Post-Dig, Damage, Vehicle, License Plates, Equipment, etc.) Witness Statement (Contractor statement, Citizen Statement, Etc.) Original One Call Ticket # Other Describe "Other"Who did you notify and what time did you notify them? Please list names of manager(s). List time AM or PM(Required)This field is hidden when viewing the formPictures of IncidentThis field is hidden when viewing the formFilePlease upload any images associated with the incident. Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, tif, pdf, mp4, heic, mov, wmv, Max. file size: 256 MB. Investigation PicturesDamage Investigation Photos(Required)Please upload damage investigation photos here. Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, tif, pdf, mp4, heic, mov, wmv, Max. file size: 256 MB. Post Locate PhotosPlease upload post locate photos from the original ticket here. Only upload pictures relevant to where the damage occurred and not every single post locate photo. Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, tif, pdf, mp4, heic, mov, wmv, Max. file size: 256 MB.
