UCG - SDU Scoping Form Version 1.1

• S/O Number & Address

• Address

• S/O Number

• Commit date

  Date

• Prepared by: Phone Number:

Disclaimer

• The assessors believe the information contained within this risk assessment report to be correct at the time of printing. The assessors do not accept responsibility for any consequences arising from the use of the information herein. The report is based on matters which were observed or came to the attention of the assessors during the day of the assessment and should not be relied upon as an exhaustive record of all possible risks or hazards that may exist or potential improvements that can be made. Information on the latest workers compensation and OHS / WHS laws can be found at the relevant State WorkCover / WorkSafe Authority.

Confidentiality Statement

• In order to maintain the integrity and credibility of the risk assessment processes and to protect the parties involved, it is understood that the assessors will not divulge to unauthorized persons any information obtained during this risk assessment unless legally obligated to do so.

Next Actions

• Was a half scope or full scope completed?

  Full scope

  Half scope

• Customer was not available at time of survey

• Type of installation ?<br>Note: Last step fibre refers to a business ( including schools) with the following criteria<br>a) No existing duct from from boundary to FTP greater than 15m<br>b) Existing duct between boundary and FTP greater than 100m <br>c ) Grater than 1 aerial span boundary to FTP

  SDU

  MDU

  ROW

  Last Step Fibre

  School

• Is the build complete? <br>E.g. In an MDU has a budi been installed in the building or on a ROW is there ducting in place

  Yes

  No

• STOP: Please contact Management to confirm.

• STOP: Please contact Management to confirm.

• What work type is to be completed?

  Select 1. Aerial (N-560) 2. Haul (N-561) 3. Ruggerdised/Surface Mount (N-562) 4. Trenching (N-563) 5. Drilling (N-564) 6. Hard Surface Reinstatement (N-565)

  • 1. Aerial (N-560)
  • 2. Haul (N-561)
  • 3. Ruggerdised/Surface Mount (N-562)
  • 4. Trenching (N-563)
  • 5. Drilling (N-564)
  • 6. Hard Surface Reinstatement (N-565)

• Aerial Linear distance greater than Ruggerdised or Haul distances, and may include
  - up to 3 sqm Hard Surface reinstatement
  - up to 5m Drilling
  - up to 5m Trenching

• Is the POLE safe to climb?

  No

  Yes

• Type of Pole

  Veerendal Type 1 Pole

  Spun Pole

  Wooden Pole

  Pole with power breaker/transformer

  Other

• Explanatory notes identifying the condition of the pole and reasons for the pole to be unsafe.

• Take photo of servicing OFDC or junction box.

  Media

• Capture pole ID and where aerial feed is connected to.

• Aerial Linear distance greater than Ruggerdised or Aerial distances, and may include
  - up to 3 sqm Hard Surface reinstatement
  - up to 5m Drilling
  - up to 5m Trenching

• Aerial Linear distance greater than Haul or Aerial distances, and may include
  - up to 3 sqm Hard Surface reinstatement
  - up to 5m Drilling
  - up to 5m Trenching

• Trenching more than 5m

• Drilling more than 5m

• Hard Surface Reinstatement greater than 3 sqm

• Chorus approval required

• Type of network?

  Air Blown Fiber Blow

  Fixed Fiber Haul

  Aerial (overhead)

• Other requirements? I.e Arborist, Obstuction Plans, etc

  No

  Obstruction plans required

  Arborist

  Other

• What is required?

• Traffic Management Required?

  LV1 TMP

  LV2 TMP

• Where is the TMP is required?

  FAT only

  Outside customers premise only

  At both the FAT and premises

  Other

Scoping Details

• NETMAP view available in job pack identifying the drop off location?

  No

  Yes

• Drop off located as per NETMAP?

  No

  Yes

• Take photo(s) of drop off clearly showing number of tubes & location relative to customer property

  Media

• Takes photos as required for possible drop off options, provide frontage & reinstatement measurements to consider new drop off lateral.

  Media

• Step by step description of build. Format x-y, activity, distance, infrastructure; e.g. 1-2, T in grass 5m, 3xR Key: H -haul; SM – Surface mount; MT - microtrench; T - trench; LL - lift & lay; R - ruggedized; D - duct; FF - Fixed Fibre; G – Grass; GD – Garden; GR - Gravel; S – Seal; C - concrete

• Extensive outside boundary work required? (e.g creation of new drop off, extending existing drop off, extending pole to boundary network)

  No

  Yes

• Explain Why? (e.g Extending the drop off from current location to communal driveway as no duct are available from current drop off to houses. Trenching for 10m in grass is required.

• Please load photos

  Media

• Please ensure that either Scoper or Management have acquired the correct UFB Asbuild (Including Measurements) and UFB CPA if we need to create new lateral.
  Check and confirm.

• Add Aerial view for planned work

  Media

• Add photos for design. Blue - existing; Red - build; Purple - future or for provisioning.

  Media

OSB Network

• Water in chambers?

  Yes

  No

  N/A

• Tapes in place?

  Yes

  No

  N/A

• FAT ID and location?

• Cabinet ID and location?

• Distance from boundary to ETP?

Additional Consents Required

• Additional ROW Consent Required?

  Yes

  No

  N/A

• Additional MDU Consent Required?

  Yes

  No

  N/A

• Additional Heritage site or Building Consent Required?

  Yes

  No

  N/A

Health, Safety and Environmental Issues

• Underfloor access?

  Yes

  No

  N/A

• Ceiling access?

  Yes

  No

  N/A

• Location of ETP?

• Gas detector required?

  Yes

  No

  N/A

• Dogs on site?

  Yes

  No

Internal information

• Preferred location of ONT?

• Preferred location of RGW?

Additional notes

• Notes

Customer Details and Consent

• Name and contact number

• Customer consent granted? Written is mandatory if on site with the customer.

  No

  Written

  Verbal

  Both

• If you are not the person who ordered service (the customer), please confirm that you are authorised to represent the customer.

  Sign

• We will carry out the work in accordance with Chorus' End User Terms (available at www.chorus.co.nz/ufb-terms).

Outside House/Building consent

• Hole excavation and trenching?

  Yes

  No

  N/A

• Removal of concrete/tiling/pavement?

  Yes

  No

  N/A

• Installation of conduit(s)?

  Yes

  No

  N/A

• Removal of existing copper line to the house?

  Yes

  No

  N/A

• Others?

  Yes

  No

  N/A

• Clean up: We will leave the property in a clean and tidy state on competition. This does not include reinstatement to the same condition.

Inside House/Building consent

• Drilling small holes?

  Yes

  No

  N/A

• Cutting holes in walls?

  Yes

  No

  N/A

• Exposed surface wiring?

  Yes

  No

  N/A

• Removal of ceiling tiles?

  Yes

  No

  N/A

• Surface mounted installation and hardware?

  Yes

  No

  N/A

• Others?

  Yes

  No

  N/A

Signed consent

• I confirm that:
  - I have seen, read and understood this information and the end user terms and accept those terms; and
  - If I am not the owner of the property, I have obtained the consent of the owner for the installation works; and
  - I understand that there may be an impact on the operation of burglar and medical alarms, particularly monitored alarms. [Note: check with your alarm provider or telecommunications service provider]

• End user signature:

  Sign

• Authorised Chorus technician:

  Sign