Incident Form - Underground Utilities
IMMEDIATELY:
Call 911 if the line is live gas, hazardous liquid, or poses an immediate threat to safety
Call your General Superintendent
Within 2 hours of the incident
Within 2 Hours:
Call 811 to self-report the incident - PLEASE NOTE TIME OF CALL & REPORT # PROVIDED BY 811
Call the line operator (Atmos, Oncor, city water utility) Oncor, city water utility) Within 24 hours of incident:
Within 24 Hours:
Complete Incident Form- Underground Utilities and email to Brandt Legal Department
Legal will report to Texas RR Commission or other authorities - DO NOT submit any independent Report.
Employee Information
Temp Employee?
*
Yes
No
First Name:
*
Last Name:
*
Date of Birth:
*
Employee ID:
Department:
*
Job Title:
*
Start Date:
Time in Trade:
Involved Employees Contact Number:
Supervisor Name:
*
Other Employees Involved:
No
Yes, Whom:
811 Called:
Yes
No
Name of other witnesses?:
Incident Information
Incident Date:
*
Incident Time:
Line hit by:
Brandt
Sub Contractor
Type of Service Factory Affected:
Distribution
Service/ Drop
Type of Service Line:
Cable
Gas
Water
Line was:
Active
New, but unused
Abandoned
Damage Occurred On:
Private Property
Easement
Public Property
Public Tie-In
Incident Caused Interruption in Line Service:
Yes
No
Pipe Material:
Cast Iron
Bare Steel
Poly-Vinyl
Coated Steel
Poly-Plastic
OTHER:
Damage Occurred To:
Coating of pipe
Body of Pipe
Other:
Pipe/Cable Diameter:
Pipe/Cable Struck By:
Depth of Pipe/ Cable at Impact Site:
Blowing, Hissing, Bubbles, or Leaking of Substance from Pipe?
Yes
No
Describe Damage Below:
Injuries Resulting from Incident?
No
Yes
If yes, must fill out a Incident Form- Injury; brief explanation below:
Dig test or Utility Marking Prior to Digging?
No
Yes
Type of markings used:
Did the excavator wait 48 hours prior to excavating
No
Yes
Hours of excavator downtime:
Estimated downtime cost:
Were pipeline facilities marked accurately?
No
Yes
Were pipeline company reps on site at the time of excavation?
No
Yes
Did the locator meet with excavator at time of marking?
No
Yes
Explain the root cause of incident below:
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811 Reporting
Name of person who called 811
Time of Call:
811 Report Number:
Texas RR Commission Incident:
Line Operator Reporting
Line Operator
Name of person who called operator:
Time of call:
Operator Report
# (if provided) :
Please wait.
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