Premise Survey Inspection Form

• Site conducted

  Select

• Business Name

• Conducted on

  Date

• Prepared by

• Location
  Address

Customer Information

• Business Name

• Address/Suite Number
  Address

• City, State, Zip

• On-Site Installation Contact

• Phone 1

• Phone 2

• Site Contact Email Addr

• Phone Integrator/ IT Consultant Info

• Phone 1

• Phone 2

• Other Customer Information?

Section A: Customer Premise Information

• Building Type

  Single Unit

  Multi Unit

• Number of existing stations/phones in office

• # of additional jacks requested by cust

• Any special/multiple wiring to phones?

• Station Wiring Type

  Homerun

  Loop

• Type of Inside Wiring

  2 pair

  CAT-3

  CAT-5

• Any other equipment ?

  Select PBX Fax POS Terminal ATM Modem Security System

  • PBX
  • Fax
  • POS Terminal
  • ATM
  • Modem
  • Security System

• Does wire routing go through other customer's locations?

  No

  *Yes

• Any special boundaries? Firewall, plenums?

• Does the customer have a UPS system for back up power?

  Yes

  No

• Does The customer have the appropriate ground for ADTRAN device?

  Yes

  No

• Section A - Additional Comments:

Section B: Customer-Furnished Information

• Does customer presently dial 9 to get an outside line?

  Yes

  No

• Who is the current Phone Provider?

• Does customer have an alarm or telephone consultant?

  Yes

  No

• Will alarm/IT/Telephone consultant be on-site for installation? <br>(List below) Will customer make arrangements?

  Yes

  No

• Does customer request a specific time for interruption?

  Yes

  No

• If *Yes, note requested time: (e.g. 8am-10am or, Noon-2 PM)

• Does customer have problems with existing service?

  No

  *Yes

• If *Yes, please note under Additional Comments, below.

• Where to physically install the equipment (ONT, NID, ETC) (List Below)?

• Section B - Additional Comments:

Section C: Telco Closet Information

• Is there a telco closet?

  Yes

  No

• Key needed to access closet?

  Yes

  No

• How far is closet from the customer's location?

• Is there 120 AC available?

  Yes

  No

• Type of Demarc

  66 Block

  110 Block

  Multi-Line NID

• Are the customer's phone lines accessible and easily identified?

  Yes

  No

• Space available to install ONT or other relevant equipment?

  Yes

  No

• Addt'l mounting equipment needed? Mounting board, cables, power cords?

  No

  *Yes

• If *Yes, please note under Additional Comments, below

• Is there a fire panel or elevator line?

  No

  *Yes

• If *Yes, where?:

• Has the fire moniotoring company been notified of provider change?*

  Yes

  No

• Fire Panel Make and Manufacturor:

• Is there a security system?

  Yes

  No

• If *Yes, where?:

• Security System Make and Manufacturor:

• known issues with the system? http://cpe/

• Any contact information on the systems:

• Is there a key system or PBX system? *Yes No

  Yes

  No

• If *Yes, where?

• System make and manufacturer:

• Any contact information on the system:

• Is there any special data equipment? (Data Only)

  Yes

  No

• If *Yes, what?

• *Customer should have notified alarm monitoring company of provider change. If they have not the should do so prior to the installation.

• Section C - Additional Comments:

Section D: Premise Survey Feedback

• How long to complete the installation job? hours:

• Is there availability on the existing OFDC?

  Yes

  No

• Any additional work past the demarcation?

• Any special equipment needed to perform the installation? (ladder, lift, core drilling, bucket truck etc.)

  No

  *Yes

• If so, list equipment

• Any possible safety concerns?

• If a new drop is required, where does it enter or penetrate the building?

• If a new outlet is required, describe route through building (rooms, closets, false ceilings, wall fish)?

• Section D - Additional Comments:

• Drop length (tap to customer in feet)

• FEET

• Pre-bury required

Section F: Surveyor Approach/Sign-Off

• Surveyor Name and Phone Number

• Date of Survey

  Date

• Summary Installation Approach: