General information

SAP Order nr

Maygurney order nr

Grid ref X

Grid ref Y


Site location



Manhole inspection ?

Manhole Inspection

Manhole number ( if known)

Start date / time
Finish date / time
Crew on site
Manhole type
Surface type

Description of works / comments

Section 81?

STW Asset?

Transferred Asset?

FOW required

Customer name

Customer mobile nr

Customer contact nr

PTD Signed

Can we carry out works at any time

Access details

Reason for no PTD

Access details

Is job a P1 , 2 , 3 or 4

Have you contacted either MARK / STEVE or NIGEL

Scheduler called to raise job?

Has the area been left safe

Protection in place ?
Why not safe ?
FOW Priority

Replace or Reset?

Cover type
Cover defect
FOW Traffic management

Approximate length of reinstatement required

Approximate width of reinstatement required

Manhole cover size

Are any manhole cover dimensions greater than 675 mm

Any manhole cover dimensions greater than 1300 mm

Schedule 13 quote required
Non standard cover order required

Cover lifted

Manhole cover depth

Reason why not lifted

Customer Special Requirements?


Specific Site detail Information

Road markings

Markings detail

Surface treatment ?

Surface treatment type

Road Width?

Distance from kerb to edge of reinstatement of running lane

Clear visibilty up road in metres

Clear visibilty down road in metres

Bus Stop within 50m?

Traffic Control within 50m?

Traffic control alterations required ?

Any parked cars at time?

Could cars park ANY time?

Speed limit

Parking suspension

Any hand dig required?

Traced and Marked?

Safety Information

Overhead Power?

Lamp Support Required?

Confined Space Working?

Any Other Safety Information?

Mitigation inspection?

Start date / time

Is problem associated with STW asset

Customer name

Customer mobile nr

Customer contact nr

Customer type

Property type ?

Areas of property to be protected

Details of flooding encountered

Is protection possible ?

Mitigation requirements / possibilities

Type of protection

Design detail proposals

Sketch of proposals

Customer special requirements with respect to mitigation measures

Is customer willing to agree to mitigation work

I / We agree to the afore mentioned works

PTD Signed

Can we carry out works at any time

Access details

Reason for no PTD

Access details

Customer Special Requirements with respect to access


Explanation of reasons

Source of problem


Description of works / comments

Draw sketch here if required.
Location photos
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.