Damage Prevention Complaint Form
Who is submitting this information?
Who is Filing the Complaint?
--None--
Property Owner
Facility Operator
Excavator
Other
Contact Name
Filed on Behalf of (Company)
Phone Number
Email
Damage or Event Details
Event Date
Address
City
State
--None--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Was There Damage to a Facility
--None--
Yes
No
What Type of Facility Operation Was Affected
--None--
Cable TV
Electric
Liquid Pipeline
Natural Gas
Sewer(Sanitary/Storm)
Steam
Telecommunications
Water
Other
What Type of Facility was Affected
--None--
Distribution
Gathering/Collection
Service/Drop
Transmission
Unknown/Other
Type of Work Performed
--None--
Agriculture
Bldg. Construction
Bldg. Demolition
Cable Television
Curb/Sidewalk
Drainage
Driveway
Electric
Engineering/Surveying
Fencing
Grading
Irrigation
Landscaping
Liquid Pipeline
Milling
Natural Gas
Pole
Public Transit Authority
Railroad
Road Work
Sewer
Site Development
Steam
Storm Drain/Culvert
Street Light
Telecommunications
Traffic Sign
Traffic Signal
Unknown/Other
Water
Waterway Improvement
Type of Excavation Equipment
--None--
Auger
Backhoe/Trackhoe
Boring
Bulldozer
Drilling
Directional Drilling
Explosives
Farm Equipment
Grader/Scraper
Hand Tools
Milling Equipment
Probing Device
Trencher
Vacuum Equipment
Unknown/Other
Notification and Marking
Was MISS DIG Notified
--None--
Yes
No
MISS DIG Ticket Number
Were Facility Marks Visible in the Area of the Excavation
--None--
Yes
No
Unknown/Other
Was the Approximate Location of Facilities Marked Accurately
--None--
Yes
No
Unknown/Other
Who is this complaint filed against?
Complaint Filed Against
--None--
Facility Operator
Excavator
Other
Enter Name of Company or Person
Contact Name
Phone Number
Email
Complaint Details
Please Choose an Apparent Cause Category
--None--
Notification Issue
Locating Issue
Excavation Issue
Miscellaneous Apparent Cause
Please Choose an Apparent Cause
--Select an Apparent Cause Category--
Narrative of Complaint
Explain Steps Taken to Resolve Dispute Prior to Filing Complaint
Submit Form