Title Page

  • Date audit undertaken

  • This request is for a Unison connection

  • Customer order #

  • Street address of premise to be provisioned
  • Connection types

    connection types.png
  • Type of connection requested

  • First and Last name of person undertaking the audit

Pole Information

  • Location of Pole
  • Where is the pole located

  • Pole type

  • State Pole type if identified above as "Other"

  • Is it a special purpose pole?

  • Approximate height in metres

  • Approximate diameter (in cms)

  • Ground restraint

  • Chorus pole tag colour

  • Chorus tag number

  • Power tag number

  • Does the pole support spans of more than 100m or street lighting

  • Number of copper service drop leads on pole

  • Number of existing power service leads

  • Number of existing fibre service drop leads

  • Are there 4 or more existing service leads in the direction you wish to provision?

  • Please take a photo of the relevant direction on the pole with 4 or more service leads

  • State all materials to be attached to the pole?

  • Please take at least 1 photo of the pole showing all connections on the pole. Annotate if possible


  • Is the proposed installation to be installed in the Power plane or Telecommunications plane?

  • The minimum qualification is line mechanic

  • Has the line mechanic been inducted onto the network by Chorus?

  • Do NOT carry out work on this asset

  • Are you familiar with Unisons agreed design standards on Chorus Poles

  • CaptureMAD.PNG
  • Can All Service separation standards be maintained? Including Chorus Network Reserved attachment positioning - Existing or Future

  • Chorus has reserved the right to deploy fibre in this area. If adequate separation cannot be maintained the connection will need to be undergrounded or the pole height increased.

  • Can ground clearance standards be maintained

  • Do ALL people undertaking this work have the required WTC/Qualifications to carry out work on these assets

  • Do NOT carry out work on this asset

Pole testing

  • Are you familiar with Chorus pole testing process

  • Visual checks

  • Hammer test

  • Probe test

  • Does the pole already have a "Caution do not climb" tag on it?

  • Do NOT carry out work on this asset and call 0800 4 NETWORK Option 2 and ensure the reference # provided by Chorus in included on this request form.

  • Visual Condition of Pole

  • Please take photos of any visible cracks showing length and depth or weaknesses in pole

  • Please take photo showing hammer and probe testing has been undertaken

  • Does the pole pass pole testing

  • Faulty pole process

    pole tag.png
  • Please enter fault job number

  • Signature of person who undertook testing


  • Please provide photos of The entire pole in relation to nearby boundaries, any additional points of interest relating to the poles use, mark up the provisioning path along the Chorus poles

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.