DQJE Service Change Worksheet v1.2

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

General Customer Information

• What is the customer name, billing address, phone number, fax number, email address, or other contact information?

• How did you hear about us?

  Select Angie's List BBB Business Solicited Coutura Dennis Dex (yellow) Existing Falcon Directory Friend Internet Prospectors Signs Stickers (panel) Tri-Lakes Directory

  • Angie's List
  • BBB
  • Business Solicited
  • Coutura
  • Dennis
  • Dex (yellow)
  • Existing
  • Falcon Directory
  • Friend
  • Internet
  • Prospectors
  • Signs
  • Stickers (panel)
  • Tri-Lakes Directory

• Are the devices grounded? What color and style are they?

  Yes

  No

  N/A

• Are there CO detectors where required? If not, inform the customer of the requirement.

  Yes

  No

  N/A

Job Proposal Information

• Scope of Work

• Are there any specific inclusions?

  Yes

  No

  N/A

• Are there any specific exclusions?

  Yes

  No

  N/A

• Have you offered the customer a verbal estimate? If yes, describe the offer.

  Yes

  No

  N/A

• When is the proposal promised?

  Date

Panel Information

• Panel Photos

  Media

• What is the voltage of the panel?

  Select 120/240 1ph 120/208 3ph 240 1ph 240 3ph (delta) 277/480 3ph 480 3 ph (delta) Other

  • 120/240 1ph
  • 120/208 3ph
  • 240 1ph
  • 240 3ph (delta)
  • 277/480 3ph
  • 480 3 ph (delta)
  • Other

• What is the amperage of the main?

  Select 50 70 90 100 125 150 175 200 225 400 600 800 OTHER

  • 50
  • 70
  • 90
  • 100
  • 125
  • 150
  • 175
  • 200
  • 225
  • 400
  • 600
  • 800
  • OTHER

• Is this panel the service?

  Yes

  No

  N/A

• What is the make of the panel?

  Select Bryant Cutler Hammer FPE GE Square D Homeline Square D QO Sylvania

  • Bryant
  • Cutler Hammer
  • FPE
  • GE
  • Square D Homeline
  • Square D QO
  • Sylvania

• What is the disconnecting means?

  Select None MCB Fused Non-Fused Other

  • None
  • MCB
  • Fused
  • Non-Fused
  • Other

• Do we need to replace the panel?

  Yes

  No

  N/A

• Panel Interior

• What type of wiring is there?

  Romex

  EMT

  Cloth Romex

  Other

• Where are the conductors entering from?

  Select Top Top/Bottom Top/Bottom/Side Sides Bottom

  • Top
  • Top/Bottom
  • Top/Bottom/Side
  • Sides
  • Bottom

• What size is the feeding nipple?

  Select .75" 1" 1.25" 1.5" 2" 2.5" 3" 3.5" 4"

  • .75"
  • 1"
  • 1.25"
  • 1.5"
  • 2"
  • 2.5"
  • 3"
  • 3.5"
  • 4"

• Is there a ground bushing on the feeding nipple?

  Yes

  No

  N/A

• Do we need to change the feeding nipple?

  Yes

  No

  N/A

• Are there 3 wire circuits? If yes, include the appropriate quantity of 2 pole breakers below.

  Yes

  No

  N/A

• Do we need a grounding bus bar?

  Yes

  No

  N/A

• Breaker Information

• Are we replacing breakers?

  Yes

  No

  N/A

• How many 1 pole 15a breakers are needed?

  Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

  • 0
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15

• How many 1 pole 15a GFCI breakers are needed?

  Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

  • 0
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15

• How many 2 pole 15a breakers are needed?

  Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

  • 0
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15

• How many 1 pole 20a breakers are needed?

  Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

  • 0
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15

• How many 1 pole 20a GFCI breakers are needed?

  Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

  • 0
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15

• How many 2 pole 20a breakers are needed?

  Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

  • 0
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15

• How many 2 pole 30a breakers are needed?

  Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

  • 0
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15

• How many 2 pole 50a breakers are needed?

  Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

  • 0
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15

• Are the any other or AFCI breaker requirements?

  Yes

  No

  N/A

Service Entrance / Meter / Outside Grounding Information

• Service Entrance / Meter / Outside Grounding Photos

  Media

• Are the service entrance conductors overhead or underground?

  Overhead

  Underground

• What size is the service entrance conduit?

  Select .75" 1" 1.25" 1.5" 2" 2.5" 3" 3.5" 4"

  • .75"
  • 1"
  • 1.25"
  • 1.5"
  • 2"
  • 2.5"
  • 3"
  • 3.5"
  • 4"

• What size are the service entrance conductors?

  Select 6 4 3 2 1 0 00 000 0000 250 300 350 400 500 Other

  • 6
  • 4
  • 3
  • 2
  • 1
  • 0
  • 00
  • 000
  • 0000
  • 250
  • 300
  • 350
  • 400
  • 500
  • Other

• What type of material is the service entrance conductors?

  Aluminum

  Copper

• Does the service entrance conduit need to be replaced?

  Yes

  No

  N/A

• Do the service entrance conductors need to be replaced?

  Yes

  No

  N/A

• Does the meter need to be replaced?

  Yes

  No

  N/A

• Do we need any ground rods?

  Yes

  No

  N/A

• If yes, how many?

  0

  1

  2

• What is the length of the ground wire to the rods?

• Do we need to install an "interconnect bridge" device?

  Yes

  No

  N/A

Inside Grounding Information

• Inside Grounding Related Photos

  Media

• Do we need to install a cold water ground?

  Yes

  No

  N/A

• What is the length of the ground wire to the cold water grounding point?

• Is the water meter bonded?

  Yes

  No

  N/A

• If no, how many clamps do we need?

  0

  1

  2

• Other information

Safety Information

• Safety Related Photos

  Media

• Are there any general safety hazards that our technicians need to be aware of?

  Yes

  No

  N/A

• Will the utility company need to disconnect the service?

  Yes

  No

  N/A

• Will any procedure involve an OSHA Risk/Hazard rating higher than 0?

  Yes

  No

  N/A

• If yes, what is that Risk/Hazard rating?

  1

  2

  3

  4

• Do we need to use a Lockout/Tagout procedure? If yes, provide details.

  Yes

  No

  N/A

Other Information

• Material List

Sketches / Photos

• Sketch #1

• Sketch #1

  Drawing

• Sketch #1 Related Photos

  Media

• Sketch #2

• Sketch #2

  Drawing

• Sketch #2 Related Photos

  Media