Title Page
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Site conducted
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CONDUCTED ON
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ELECTRICAL WORKER NAME
- ANTHONY HOPKINS
- DAN HUTTON
- HARRY PYMONT
- BEAU HARRIS
- ALEC DANELUTTI
- CALLUM COLLINS
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SAFETY OBSERVER NAME
- ANTHONY HOPKINS
- DAN HUTTON
- HARRY PYMONT
- BEAU HARRIS
- ALEC DANELUTTI
- CALLUM COLLINS
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TRAFFIC CONTROLLERS NAMES
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SITE CONDITIONS
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HAVE ALL MEMBERS OF THE WORK GROUP SIGNED ONTO THE RISK ASSESSMENT AND APPLICABLE SWMS FOR THE WORK
POLE INSPECTION
- POLE INSPECTION
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STREET ADDRESS
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CONDUCTED ON
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IS THE RATE 3 LABEL AND POLE ID LABEL VISIBLE?
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WHICH LABEL NEES TO BE REPLACED?
- GREEN 3
- POLE ID
- BOTH
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POLE NUMBER
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Pole Height
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Confirm pole type
- BPM
- SBM
- Hinged
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Out Reach Size
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Out Reach Type
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Out Reach Type
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Out Reach Type
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Out Reach Type
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Out Reach Size
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Out Reach Type
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Out Reach Type
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Out Reach Type
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Out Reach Type
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Out Reach Size
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Out Reach Type
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Out Reach Type
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Out Reach Type
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Out Reach Type
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CAN POLE BE SAFELY ACCESSED?
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WHY CAN THE POLE NOT BE ACCESSED?
- CAR/ VEHICLE PARKED IN WAY
- LOCATED IN PARK
- CONSTRUCTION SITE
- POLE MISSING
- OTHER - PLEASE SPECIFY
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PHOTO OF ENTIRE POLE
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PHOTO OF POLE NUMBER
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RECORD LUMINAIRE TYPE/SIZE
- L80-25-L3 :Cree STR-LWY-2S-__-08-E-UL-525-40K-CONFIGURED – 133W
- L40-3M-L3 :Cree STR-LWY-3M-__-04-E-UL-350-40K-CONFIGURED – 44W
- L20-3M-L3 :Cree STR-LWY-3M-__-02-E-UL-350-40K-CONFIGURED – 24W
- SYLVANIA- RoadLED Midi 100W 4K Aeroscreen
- SYLVANIA- StreetLED3 24W Aeroscreen
- SYLVANIA- StreetLED3 17W 4K Aeroscreen
- Other
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What Type ?
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CHECK LUMINAIRE TIGHT/LEVEL CONNECTION TO OUTREACH
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HAS THE ISSUE BEEN RECTIFIED
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WHAT IS THE ISSUE
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CLEAN/WIPE DOWN LUMINARE FITTING
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REPLACE PE CELL
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IS THE GASKET FITTING CORRCTLY
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CAN IT BE FIXED ONSITE
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IS THE FITTING OPERATIONAL?
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CAN THE FAULT BE EASILY DETERMINED?
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WHAT IS THE CAUSE OF THE FAULT?
- NO POWER TO GEAR TRAY
- POLE CIRCUIT BREAKER FAILED/ FAULTY
- POLE ISOLATOR FAILED/FAULTY
- OTHER- PLEASE SPECIFY
- Faulty Light Fitting
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CONFIRM ALL LED MODULES WORKING
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HOW MANY LED'S ARE NOT WORKING?
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PHOTO OF COMPLETED WORKS
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HAVE YOU COMPLETED A TOP DOWN INSPECTION OF THE POLE?
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WHY NOT?
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WERE ANY OF THE FOLLOWING ISSUES IDENTIFIED?
- DAMAGED HATCH SCREW
- ANT OF BUG INFESTATION
- INCORRECTLY WIRED
- NO ISOLATOR IN POLE
- NO ISOLATION POINT
- NO FUSED CABLE JOINT AT PIT ( JU POLES)
- FAULTY CIRCUIT BREAKER
- FITTING FULL OF WATER
- DAMAGE TO POLE
- DAMAGE TO GROUT
- POLE BASE BELOW FINISHED SURFACE
- OTHER -PLEASE SPECIFY
- Faulty Light Fitting
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HAS THE SITE BEEN LEFT NEAT AND TIDY, HAS THE POLE HATCH BEEN SECURED, HAVE SWITCHBOARDS BEEN CLOSED?
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ANY OTHER THINGS TO REPORT?
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PLEASE PROVIDE DETAILS
COMPLETION
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HAVE ALL POLES BEEN CLOSED UP, HATCH SCREWS SECURED AND SWITCHBOARDS BEEN CLOSED AND LOCKED?
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ARE ALL LIGHTS /CIRCUITS BACK ON?
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HAS ANYTHING BEEN TAGGED OUT / MADE SAFE THAT REQUIRES FURTHER ATTENTION?
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PLEASE PROVIDE DETAILS
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HAVE ALL TRAFFIC CONTROL DEVICES BEEN REMOVED FROM SITE?
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HAS ALL WASTSE BEEN REMOVED FROM SITE?
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HAVE ANY INCIDENTS OR NEAR MISSES OCCURED?
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