Page 106 - CCGA Best Practices Version English

Appendix D: DIRT Field Form &
Appendix D: DIRT Field Form &
Root Cause Tip Card
Root Cause Tip Card

FRESH DIRT (beginning 2018) Rev: 9/27/2017
‘*’ indicates a Required Field
Damage Information Reporting Tool (DIRT) - Field Form

Part A – Original Source of Event Information
Who is providing the information? Electric Engineer/Design Equipment Manufacturer
Excavator Liquid Pipeline Locator Natural Gas Private Water
Public Works Railroad Road Builders Federal / State Regulator
Telecommunications Unknown/Other
Name of person providing the information:

Part B – Type, Date, and Location of Event
Type of Event: DIRT Event Underground Damage Underground Near Miss
Non-DIRT Event Above Grade Aerial Natural Cause Submarine

*Date of Event: (MM/DD/YYYY)

*Country *State *County City

Street address: Nearest Intersection:

Latitude/Longitude: Lat: Lon Decimal Degrees D M S

*Right-of-Way where event occurred
Public: City Street State Highway County Road Interstate Highway Public-Other
Private: Private Business Private Land Owner Private Easement
Pipeline Power /Transmission Line Dedicated Public Utility Easement
Federal Land Railroad Unknown/Other

Part C – Affected Facility Information
*What type of facility operation was affected? Cable Television Electric Liquid Pipeline
Natural Gas Sewer Steam Telecommunications Water Unknown/Other

*What type of facility was affected? Distribution Gathering Service/Drop Transmission Unknown/Other
Was the facility part of a joint trench? Yes No Unknown
Did this event involve a Cross Bore? Yes No
Was facility owner One Call Center member? Yes No Unknown
If No, is facility owner exempt from One Call Center membership? Yes No Unknown
Measured Depth Embedded in concrete/asphalt pavement <18” / 46 cm Measured depth
From Grade 18” – 36” / 46 - 91 cm >36” / 91 cm from grade _____in/cm

Part D – Excavation Information
*Type of Excavator Contractor County Developer Farmer Municipality
Occupant Railroad State Utility Unknown/Other

*Type of Excavation Equipment Auger Backhoe/Trackhoe Boring Bulldozer
Drilling Directional Drilling Explosives Farm Equipment Grader/Scraper Hand Tools
Milling Equipment Probing Device Trencher Vacuum Equipment Unknown/Other

*Type of Work Performed Agriculture Bldg. Construction Bldg. Demolition Cable Television
Curb/Sidewalk Drainage Driveway Electric Engineering/Survey
Fencing Grading Irrigation Landscaping Liquid Pipeline Milling
Natural Gas Pole Public Transit Auth. Railroad Road Work Sewer
Site Development Steam Storm Drain/Culvert Street Light Telecommunication
Traffic Signal Traffic Sign Water Waterway Improvement Unknown/Other

Part E – Notification and Locating
*Was the One-Call Center notified? Yes No Ticket Number

If Yes, type of locator Facility Owner Contract Locator Unknown/Other

If No, is excavation activity and/or excavator type exempt from notification? Yes No Unknown
Was work area white-lined? Yes No Unknown

Part F – Intentionally left blank

Canadian Common Ground Alliance Canadian Common Ground Alliance
Canadian Common Ground Alliance
Canadian Common Ground Alliance
Best Practices Version 3.0 – October 2018
Best Practices Version 1.0 – October 2014 Best Practices Version 1.0 – October 2014
Best Practices Version 1.0 – October 2014
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