DAMAGE / CUSTOMER COMPLAINT / RESTORATION INCIDENT REPORT
Complete this form as soon as practical after a damage, customer complaint, service impact, or restoration event.
1. INCIDENT IDENTIFICATION
Incident Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time:
Hour Minutes
AM
PM
AM/PM Option
Reported Date / Time:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employee Email:
example@example.com
Reported By:
First Name
Last Name
Phone/Email:
Work Order / Job #:
Crew / Subcontractor:
Supervisor/Foreman:
First Name
Last Name
Location / Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
GPS / Pole / Facility ID:
2. DAMAGE / CUSTOMER IMPACT
Incident / Damage Type:
Customer Complaint Received?
Yes
No
Customer Impact:
Yes
No
Property / Facility Damage:
Service / Outage Impact:
Describe What Happened:
3. IMMEDIATE RESPONSE & RESTORATION
Time Damage Discovered:
Hour Minutes
AM
PM
AM/PM Option
Time AT&T / Customer Notified:
Hour Minutes
AM
PM
AM/PM Option
Restoration Start:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Restoration Complete:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Restoration Status:
SLA / Target (hrs):
Customer Updated?
Yes
No
Escalation?
Yes
No
Temporary Repair / Mitigation:
Permanent Restoration Performed:
4. ROOT-CAUSE ANALYSIS
Root Cause Category:
Dig/Excavation Damage
Utility Locate Error
Workmanship
Other
Contributing Factors:
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Root Cause Statement:
5-Why / RCA Analysis:
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5. CORRECTIVE / PREVENTIVE ACTION
Corrective Action Taken:
Preventive Action:
Action Owner:
First Name
Last Name
6. CUSTOMER COMPLAINT & FINAL RESOLUTION
Complaint Type:
Assigned To:
First Name
Last Name
Complaint Description:
Customer Communication / Updates:
Final Resolution:
Customer Notified of Resolution?
Yes
No
Customer Satisfied?
Yes
No
Unknown
Closed Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Closed By:
First Name
Last Name
7. SUPPORTING RECORDS / ATTACHMENTS
Photos Attached To Company Cam?
Yes
No
Count:
Supporting Documents Attached?
Yes
No
Count:
Locate / Ticket Number:
Other Record Reference:
Additional Notes:
8. SUBMITTER CERTIFICATION / REVIEW
I certify that the information provided is accurate to the best of my knowledge and that supporting records have been identified where applicable.
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Submitter Name:
First Name
Last Name
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature:
Reviewer Name:
First Name
Last Name
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature:
Internal Use: Review for reporting requirements, restoration timeliness, root cause, corrective action, customer communication, and record retention.
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