Title Page

  • Customer

  • PSA/Work Order Number

  • Work Date and Start Time

  • Client / Site

  • Location.. Please drop pin at work location and enter site address if any.

Crew Infirmation

  • Supervisor

  • Crew Leader

  • Crew Member 1

  • Crew Member 2

  • Crew Member 3

  • Crew Member 4

Work Completed.

  • Type of work completed?

  • Type of Splice

  • Description of Work Completed Today / Fibers spliced

  • HH or MN Location:

Commscope

  • Type of Case:<br>

  • Type of trays used and how many:

  • MST/FDT Type:

  • MF02 Drop Footage

Cable A Information

  • Cable ID

  • Direction

  • Enclosure Footage Marker

  • Pipe Footage Marker

Cable B Information

  • Cable ID

  • Direction

  • Enclosure Footage Number

  • Entry/ Pipe Footage Marker

Cable C Information

  • Cable ID

  • Direction

  • Enclosure Footage Number

  • Entry/ Pipe Footage Marker

Cable D Information

  • Cable ID

  • Direction

  • Enclosure Footage Number

  • Entry/ Pipe Footage Marker

Photos

  • Pictures of Rack RU, Panel front and back, site after work completed

  • Picture of Slack Basket

  • Picture tray 1

  • Picture tray 2

  • Picture tray 3

  • Picture tray 4

  • Picture tray 5

  • Picture of Case Closed

  • Picture of plugs and gel pack

  • Picture of cable tags

  • Picture of case in the hole

  • Picture of hole closed

Complete Date and Time

  • NOC Release Time / Time of hands off

Pre-Task Checklist

Weather

  • Weather Conditions

  • Temp

  • Additional Steps Taken For Weather Conditions

Site Setup Checklist

  • Required PPE?

  • Signs and Cones Placed

  • Wheels Chocked?

  • Customer Notification Completed?

  • Stretching/Warmup Completed?

Recognized Hazards (Check all that apply)

  • Chemicals

  • Pedestrian/Vehicle Traffic

  • Job Access

  • Co Vehicle Placement

  • Struck By’s

  • Pinch Points

  • Slips Trips and Falls

  • Excessive Noise

  • Eye Injury

Hazard Protection

  • Hearing Protection

  • MSDS Present

  • Equipment Inspection Completed

  • Flagged or Traffic Control Needed

Pre-Task Review

  • Discuss Yesterday’s Incidents

  • Site Safety Orientation Complete

  • Job Scope Understood

  • Good Catch Documented

  • Site Safety Assessment Completed

  • Additional Comments

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.