Safety and Labor-Management Relations
Incident Report Form
Department of Labor & Industry Bureau of Labor Law Compliance Underground Utility Line Protection Act
Within 10 business days of the incident, complete this form and press the submit button at the end. Digital pictures cannot be attached to this online submission. Please e-mail them to eramsay@state.pa.us with a text message to the BLLC asking that the pictures be attached to the Incident Report form along with the Confirmation Number.   If you are facility owner or excavator, is your organization a member of the Pennsylvania One Call system, Inc?
Reported By
First Name  Last Name 
Company Name:  Date(mm/dd/yyyy):  
Address - Line 1    Telephone/  
Address - Line 2  Fax/ 
City   State  E-Mail 
Zip Code 
Excavator Performing Work 
 
Contact Person:
First Name   Last Name  
Address - Line 1    Telephone / 
Address - Line 2 Fax/ 
City  State 
Zip Code   E-Mail 

Nature and scope of excavation: 

Type of equipment being used: 
Date excavation started(mm/dd/yyyy)        
Time of excavation started(hh:mm am/pm)
Was the area marked in white? 
Was PA ONE CALL contacted? If so, fax or mail copy.  POCS Serial #:
Was it called in as an emergency? 
Nature of emergency:
Did the facility owner respond to KARL? 
What was the response?
Date of response(mm/dd/yyyy):    
Time of response(hh:mm am/pm):
Incident Information

Facility Name                               Date of Incident(mm/dd/yyyy)  

County                                            Time of Incident(hh:mm am/pm) 

Municipality                                  Address   

City                                              Zip Code    
Damage to facility? 
Type of facility: 

Size of facility (diameter): 

Facility owner's name:      
Facility Use: 
(Explain Other)
Right of Way 
Interruption of service: 
Duration of Interruption:  

Start Date(mm/dd/yyyy)                  End Date(mm/dd/yyyy)

Start Time(hh:mm am/pm)                End time(hh:mm am/pm)
Number of customers affected:          Number of customers evacuated: 
Were lines located? 

Date lines were marked(mm/dd/yyyy):  

Time lines were marked(hh:mm am/pm):
Was size indicated? 
Colored Indicator: 
Personal injury? 
Number injured? 
Death? 
Number fatalities 
In the event of damage, did the excavator notify the facility owner? 
Evacuate/alert resident(s)? 
1. If you are a facility owner reporting a hit, was the hit made by your employees? 
2. If you are a facility owner reporting a hit, was the hit made by a contractor that you hired? 
3. If you are a facility owner reporting a hit, did you hit another facility owner's line? 
4. If you are a contractor/excavator reporting a hit that you made, were you hired by the facility owner of the line that you hit? 
5. If this was a gas line hit, was it a gas transmission or gas distribution line? 
Explanation of Incident: (Attach extra paper if necessary) 
Provide a detailed sketch of the incident area: (Attach extra paper if necessary) To accurately describe the incident, please include the following (1) direction of north, (2) the underground utilities, roads, fixed landmarks, etc, (3) location of incident using distance landmarks, (4) the location of paint or flags placed by the facility owner and (5) the distance between the incident and the paint or flags.
Whom do you represent? 

I herby verify that the statements contained in this Incident Report are true and correct to the best of my knowledge, information and belief. I understand that false statements made are subject to the penalties of 18 Pa. C.S.A. 4904, relating to unsworn falsification to authorities.


If Disgree is selected the Incident will be submitted but can not be Investigated

 
                                                                                                                                                               

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