Part B - Submitter Information
Contact First Name:
Contact Last Name:
Contact Work Phone:
Contact Mobile Phone:
Was This Matter Brought Before The LDPM:
If So, When:
Part C - Incident Information
Incident Date & Time:
Name Of Party In Violation:
Was There A Statute Violated:
If yes, Please Specify Which Statute Was Violated:
Part D - Excavator Information
Part E - Excavator Category
Part F - Type of Excavation Activity
Part G - Type of Excavation
Method of Excavation:
Part H - Description of Damage
Type of Facility:
Utility Line Function:
Part I - Incident Impact
Did the fire department respond?
Did the police department respond?
Was evacuation necessary?
Was traffic stopped or detoured?
Was there a service interruption?
Excavation Down Time Cost:
Number of Fatalities:
Number of Injuries:
Number of Customers Affected:
Damage Repair Cost:
Other Property Impacted:
Other Property Repair Cost:
Part J - Notification Center Information
Did the person have a valid ticket?
Did the person check Underground Facilities Information Exchange System?
Type of Ticket:
Part K - Locating/Marking of Utility Line
City, State, Zip:
Was the line marked prior to the damage?
What types of marks were present?
Condition of the marks in the proposed excavation area:
Were facilities visible in the excavation area?
If "Yes", indicate record type:
Were facilities marked in accordance with Maryland law and local practices?