Near-Miss Report Form
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1
2Commonwealth of Virginia
State Corporation Commission
Underground Utility Damage Prevention Act
Near-Miss* Report Form
Please provide all information requested here to assist in conducting a thorough investigation of this incident. This information
will also help build a database to guide us in furthering damage prevention in Virginia. Please use a separate report for each
incident. Thank you for your time.
Part A – Please send this information to:
Division Use Only
Damage Prevention Investigator
Commission Toll Free Number ............. 1-800-552-7945
Division of Utility and Railroad Safety
Division Number ........................................ 804-371-9980
Report No: _______________
State Corporation Commission
FAX .............................................................. 804-371-9734
P.O. Box 1197
Email ........... vadamageprevention@scc.virginia.gov
Investigator: ______________
Richmond, Virginia 23218
Web ..................
Part B – Who is submitting this information:
Date of this report:
Name:
Work Phone:
Company:
Mobile Phone:
Address:
Home Phone:
City, State, Zip:
Pager Number:
Email:
FAX:
Part C – Incident information:
Incident Location:
Incident Date and Time:
Public Property
City Right of Way
Incident Address:
Private Property
County Right of Way
City/County:
Zip Code:
Utility Easement
State Right of Way
Cause:
Latitude:
Longitude:
Part D – Excavator Information:
Date and Time Excavation Began:
Name:
Work Phone:
Company:
Mobile Phone:
Address:
Home Phone:
City, State, Zip:
Pager Number:
Email:
FAX:
Part E – Work Done For:
Company/Individual Name:
Federal government
Utility
Property owner/occupant (individual)
State government
Railroad
Property owner/leaser (business)
Home builder
Local government
Farmer
Other:
Site developer
Road builder
Realtor
Part F – Type of excavation activity:
Parallel excavation
Yes
No
Exposing (pot holing) facility
Yes
No
Agricultural
Drainage work
Lot grading
Traffic signal/system
Installing Utilities:
Bldg. construction
Driveway work
Plumbing/septic work
Road construction
Electricity
Bldg. demolition
Fence work
Roadway maintenance
Setting poles
Telecommunications
Bldg. reconstruction
Investigating gas leak
Sign installation
Sprinkler
Cable
Gas
Curb/sidewalk work
Landscaping
Site development
Other:
Sewer
Water
Part G – Type of excavation equipment:
Equipment Type and Model:
Mechanical
Hand
Vehicle
Method of excavation:
Boring*
Explosive
*If method is “boring,” select technique:
Augering
Ditching
Grading
Paving
Scraping
Horizontal Directional Drilling (HDD)
Barholing
Dredging
Hand Digging
Plowing
Tilling
Jack and Bore
Blasting
Drilling
Moving
Razing
Trenching
Pneumatic Missile (thumper, holehog, etc.)
Boring*
Driving
Pavement Milling
Removing
Tunneling
Other:
Digging
Rendering
Wrecking
Page 1 of 2
DPA-1 Report Form Revised June 2014
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