Information
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Document No.
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Conducted on
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Foreman
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Crew Leader
- Pat
- Chad
- Justin
- Bill
- Braden
- Shane
- Josh
- Randy W.
- Steve
- Nate
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Personnel
- Dave
- Pat
- Chad
- Justin
- Josh
- Bill
- Braden
- Shane
- Randy W
- Steve
- Tom
- Nate
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Work Order
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Rescue 911 Address
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Weather
- Sunny
- Raining
- Windy
- Overcast
- Snowy
- Cold
- Night
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Hot Job
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An element of interaction with 7200/12470 is assumed on all "Hot Jobs" both primary and secondary
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Primary or Secondary
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Type of Wire?
- ACSR
- Cooperweld
- Primary URD
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Able to get a one-shot?
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One Shot Location:
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Direction of Feed?
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Fill out the information below for the source of one side of the Two-Way-Feed
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Type of Protective Device?
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Size of Fuse?
- 10 AMP
- 15 AMP
- 25 AMP
- 30 AMP
- 50 AMP
- Other
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Size of Breaker?
- 25 H
- 35 H
- 50 H
- 35 L
- 50 L
- 70 L
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Substation and Feeder
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Location of Nova/Triple Single
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Fill out the information below for the next source coming into the Two-Way-Feed
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Type Of Protective Device?
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Size of Fuse
- 10 AMP
- 15 AMP
- 25 AMP
- 30 AMP
- 50 AMP
- Other
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Size of Breaker
- 25 H
- 35 H
- 50 H
- 35 L
- 50 L
- 70 L
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Substation and Feeder?
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Location of Nova/Triple Single
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Location of Protective Device for URD?
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Is switching required?
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Switching type?
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Secondary Voltage
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PPE to be used?
- Hard Hat, Safety Glasses, Steel Toe Boots, FR Clothing
- Work Gloves
- Rubber Gloves
- Sleeves
- Hard Cover
- Rubber Cover
- Face Shield
- Hi-Vis-Vest
- Hearing Protection
- Other
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Other?
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Is Climbing required?
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Pole Condition?
- Good
- Structural damage
- Badly leaning
- Other
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Other?
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Is Digging required?
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Is there a locate?
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Take a picture of locate marks. Write down ticket # if known.
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Ticket Number
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Take a picture of the locate marks
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Is work to be done on/near a roadway?
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Road type?
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INDOT notified
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Traffic Control Plan in Place?
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Is flagging required?
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Why not?
- 15 minutes or less
- 10 feet from the fog line
- No traffic on roadway
- Other
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Other
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Flaggers Means of Communication?
- Hand Signals
- Two-Way Radio
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Traffic control devices to be used?
- Utility Work Ahead Sign
- One Lane Road Ahead Sign
- Flagger Ahead Sign
- Block Vehicle
- Cones Around Trucks
- 1st. Responder Assistance
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Traffic Control devices to be used?
- Utility Work Ahead Signs
- Cones Around Trucks
- Other
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Will grounds be applied?
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Location of Grounding Points?
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Additional Information to be included?
- Information
- Pictures
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Additional Information
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Additional Pictures
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Signing
Person
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Initials Here
