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CONNECTICUT
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DIAL 811 or 1-800-922-4455

PURA Incident Report Form

Click here for detailed form instructions
A report is required to be filed by the owner of underground facilities (16-345-3(a)(3) regulations of conn. state agencies). connecticut statutes allow PURA to levy a civil penalty up to $40,000 for failure to comply with anyprovision of the statute or regulations. this report may be used in actions imposing a civil penalty for violation of the statutes and regulations.

Therefore, FILL OUT THIS FORM ACCURATELY, AND FILE NOT LATER THAN THE 15th OF THE MONTH FOLLOWING THE INCIDENT. CBYD, Inc. acts as an information clearinghouse, and assumes no liability or prosecutorial position in compiling and transmitting these records.

This incident resulted in: (check one)
DAMAGE TO FACILITIES
NO DAMAGE TO FACILITIES
This Report prepared on:
/ /
I. Teletype/Utility Code:
Utility Name:
Mailing Address:
City:
State:
Zip code:
Report prepared by:
Email:
II. Excavator involved in Incident:
Mailing Address:
City:
State:
Zip Code:
Contact Person:
Telephone:
Email:
III. Date & Time of Incident:
/ / time:
CBYD Ticket #:
Street address of Incident:
City:
Check Utility affected:
Communications
Water
Sewer
Electric
Gas


Check Facility:
Main
Service


Check Incident Location:
Private R.O.W.
Public R.O.W.




IF DAMAGE resulted, enter ONLY ONE Primary Cause letter code from the Table below:
  • M No notice (no CBYD ticket)
  • N Not located-Markout person error or omission
  • O Not located; less than 2 full working days - Emergency excavation, or No emergency (explain in COMMENTS)
  • S Not located-Incorrect or Incomplete notice
  • V Not located-Incorrect record
  • U No record of facility, or incorrectly located
  • P Failure of excavator to maintain marks
  • Q Failure to Hand Dig (required for GAS facilities only)
  • R Failure to exercise Reasonable Care (Explain in Comments)
  • X Failure to stay within the proposed Work Area.
  • W Located Incorrectly-Incorrect record of facility
  • Z Located Incorrectly-Markout person error or omission
VIOLATIONS OF REGULATIONS -CHECK  ALL THAT APPLY FROM THE TABLE BELOW:
Excavator AT FAULT
  • 1 No notice (no CBYD ticket)
  • 2 Failure to wait 2 full working days -not an emergency
  • 3 Failure to adequately and properly describe location
  • 4 Failure to renew notice (CBYD Ticket>30 days old)
  • 5 Failure to white line proposed work area
  • 6 Improperly declared emergency
  • 7 Failure to hand dig (gas only)
    Thickness of bituminous and concrete surface: in.
    Cover over facility: in.
  • 8 Failure to maintain marks
  • 9 Failure to adequately support facilities
  • 10 Failure to report damages and contacts
  • 11 Unauthorized tampering with utility facilities
  • 12 Failure to exercise reasonable care (describe under COMMENTS,below)
Facility Owner/Operator at fault
  • 13 Failure to mark facilities-No record; incorrect record
  • 14 Failure to mark facilities-markout person error or omission
  • 15 Failure to mark facilities-did not mark facilities-other (e.g.,no one dispatched)
  • 16 Failure to mark accurately-no record, incorrect record
  • 17 Failure to mark accurately-markout person error or omission
COMMENTS:
IV. Did incident cause interruption of service?
No  Yes Time of outage
Duration of outage:
hours
Number of customers affected by outage:
Number evacuated: Number of personal injuries: Number of fatalities:
V. Will excavator be billed for Incident?
Yes No
VI Supervisor's Approval
Job Title
Approve Date
Phone
CC
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