DoT Surveillance Advice

• Site conducted

  Select

• Region

  Select

• Document #

• Date

  Date

• For Attention of

• Company

  Select

• What is the Company Name

• Subject

• Issued By

• Location
  Address

• Contract reference should include the section and clause that is applicable from the contract

• Contract Reference

  Select

• Details should include as much information as possible including dimensions L x W x D = V or exact chainage locations, a description of what is being removed or not done. can include multiple items. No agreement for costs, for records purposes only.

• Is this notification of a hold point release after a proof roll?

  Yes

  No
Layer Details

• Start Chainage

• End Chainage

• Layer name

  Select

• Has the proof roll Passed or Failed

  Pass

  Fail

  N/A

• Have you seen a passing test result for the layer?

  Yes

  No

• Add a Photo of Result

• Comments

• Details

• Sketch

  Drawing

• Photo's

  Media

• Type of Surveillance Advice

  OBSERVATION

  NON-COMPLIANCE

• I advise that the above item(s) of work does not comply with the requirements and / or your Quality Plan for the above contract. Would you please advise of your intended action in accordance with your Quality Plan and the contract, Number of days to respond is:

  Select

• Can work on the above Item(s) continue until advice of your intended action is received?

  Yes

  No

  N/A

• WARNING: Work is not to proceed on the above item(s) until advice of your intended action is received and accepted below

• Work can proceed on the above item(s) until advice of your intended action is received and accepted below

• Contractors Non-conformance number and date:

• Can work on the above item(s) now resume?

  Yes

  No

  N/A

• This confirms my verbal advice to you regarding the above item(s) of the work. Verbal advice date

  Date

• Issued By RRV (Signature)

  Sign

• Received By Contractor (Signature)

  Sign

• COPY TO: CONTRACTOR / CONTRACT ADMINISTRATOR / FILEIT

Completion Information

• Date Completed / Rectified

  Date

• If Work Stopped, Date Work Resumed

  Date

• Extension of Time Applicable in Days

• Completed By

• Comments / Resources / Details

• Photo's

  Media