Title Page
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Customer
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PSA/Work Order Number
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Work Date and Start Time
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Client / Site
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Location.. Please drop pin at work location and enter site address if any.
Crew Infirmation
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Supervisor
- Steve Dull
- Randy Carlton
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Crew Leader
- Randy Carlton
- Steve Dull
- Bruce Bennett
- Chris Gambill
- Nick Vanlieshout
- Joel Bakken
- Landen Presfield
- Zack Stout
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Crew Member 1
- Randy Carlton
- Steve Dull
- Bruce Bennett
- Chris Gambill
- Nick Vanlieshout
- Joel Bakken
- Landen Presfield
- Zack Stout
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Crew Member 2
- Randy Carlton
- Steve Dull
- Bruce Bennett
- Chris Gambill
- Nick Vanlieshout
- Joel Bakken
- Landen Presfield
- Zack Stout
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Crew Member 3
- Randy Carlton
- Steve Dull
- Bruce Bennett
- Chris Gambill
- Nick Vanlieshout
- Joel Bakken
- Landen Presfield
- Zack Stout
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Crew Member 4
- Randy Carlton
- Steve Dull
- Bruce Bennett
- Chris Gambill
- Nick Vanlieshout
- Joel Bakken
- Landen Presfield
- Zack Stout
Work Completed.
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Type of work completed?
- Splicing
- Macro Corning 72 ct. Panel
- ISP Cable Installation
- Case Re Entry
- MISC
- Testing
- Troubleshooting
- Panel Installation
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Type of Splice
- Macro 72ct Panel Splice
- Butt Splice
- Ring Tap Splice
- Fiber Turn
- Testing
- MF02 Butt
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Description of Work Completed Today / Fibers spliced
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HH or MN Location:
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Permit Number:
Commscope
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Type of Case:<br>
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CommScope 24R
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Used Existing Tray 24R
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Used Existing Tray 72S
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CommScope 72S
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CommScope B Tray
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Type of trays used and how many:
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MF02 Type:
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MF02 Drop Footage
Cable A Information
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Cable ID
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Direction
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Enclosure Footage Marker
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Pipe Footage Marker
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PID Number
Cable B Information
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Cable ID
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Direction
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Enclosure Footage Number
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Entry/ Pipe Footage Marker
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PID Number
Cable C Information
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Cable ID
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Direction
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Enclosure Footage Number
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Entry/ Pipe Footage Marker
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PID Number
Cable D Information
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Cable ID
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Direction
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Enclosure Footage Number
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Entry/ Pipe Footage Marker
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PID Number
Photos
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Pictures of Rack RU, Panel front and back, site after work completed
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Picture of Slack Basket
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Picture tray 1
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Picture tray 2
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Picture tray 3
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Picture tray 4
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Picture tray 5
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Picture of Case Closed
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Picture of plugs and gel pack
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Picture of cable tags
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Picture of case in the hole
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Picture of hole closed
Complete Date and Time
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NOC Release Time / Time of hands off
Pre-Task Checklist
Weather
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Weather Conditions
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Temp
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Additional Steps Taken For Weather Conditions
Site Setup Checklist
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Required PPE?
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Signs and Cones Placed
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Wheels Chocked?
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Customer Notification Completed?
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Stretching/Warmup Completed?
Recognized Hazards (Check all that apply)
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Chemicals
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Pedestrian/Vehicle Traffic
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Job Access
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Co Vehicle Placement
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Struck By’s
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Pinch Points
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Slips Trips and Falls
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Excessive Noise
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Eye Injury
Hazard Protection
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Hearing Protection
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MSDS Present
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Equipment Inspection Completed
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Flagged or Traffic Control Needed
Pre-Task Review
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Discuss Yesterday’s Incidents
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Site Safety Orientation Complete
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Job Scope Understood
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Good Catch Documented
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Site Safety Assessment Completed
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Additional Comments
