A55

A55
Engineer Name*

First NameLast Name
Exchange*
DateTime
Job Reference*

LMJ/MMJ/PON IDWhat Build is being affected
Site Co-ordinates
Location Description*
House Number/Name*
Road Name*
Post Code*
No. of Cables in situ:*
Bore Space*
Duct Section*
Duct Section Length (M)*
Activity*
How many?*
Surface Type?*
Soft Meterage (M)*
Footway Meterage (M)*
Carriageway Meterage (M)*
Box Type*
Activity 1 Co-ordinates (X & Y on GPS OS)*
Whilst standing by the activity, please copy and paste the X&Y co-ordinates from GPS OS
Activity 2 Co-ordinates (X & Y on GPS OS)*
Whilst standing by the activity, please copy and paste the X&Y co-ordinates from GPS OS
Chamber Location*
Pole Location*
TM Required?*
Lane ClosureFootway Closure2-Way LightsMultiway LightsRoad Closure
Metres Rodded from Box A*
Metres Rodded from Box B*
Unproven Amount (M)*
Reason*
Please call Network Assurance Operations Control on 03301233304 to ascertain reason for D-Pole
Is a Core Drill required?*
Quantity of Core Drills?*
Each end of the duct section times by the amount of ducts being laid.
Describe the Extent of the Tree Cutting*
Are you meeting existing duct or going to an existing chamber?*
Distance to Duct/Box? (M)*
Chamber Type*
Distance (M)*
Notes *
Please add additional notes
Congested DuctUnpoenable BoxBlockageTMA
Please go onto mapping site (Orion, GeoHub, Google) & screenshot your work area. Annotate the image and then upload the image in the field below.
Annotated Map*

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Box Lid 1, if applicable (Take a few metres back to show surroundings)*

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Box 1 Open with 25mm Rod and Duct Mouth Sprayed, if applicable*

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Box 1 Co-ordinates (X & Y on GPS OS)*
Whilst standing on the box, please copy and paste the X&Y co-ordinates from GPS OS
Box 1 Type*
Box Lid 2, if applicable (Opposite End of section) *

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Box 2 Open with 25mm Rod and Duct Mouth Sprayed, if applicable*

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Box 2 Co-ordinates (X & Y on GPS OS)*
Whilst standing on the box, please copy and paste the X&Y co-ordinates from GPS OS
Box 2 Type*
Blockage 1 Marked on Ground with Spray, if applicable*

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Blockage 2 Marked on Ground with Spray, if applicable*

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Surroundings photo, if applicable (Showing the blockages marked up and its surroundings)*

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Base of Pole with Boot Removed, if applicable*

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First/Start Pole DP Number and if it's a D-Pole, if applicable*

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Location of Required New Box Spray Marked on the Ground, if applicable*

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Reason for New Frame & Cover, if applicable (Damage/Unable to Open Seized Shut)*

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Location of Box with Surroundings to ascertain if TM is Required, if applicable*

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Second/End Pole DP Number and if it's a D-Pole, if applicable*

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Photo of Carriageway, if applicable*

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Picture 1 showing trees that require cutting, if applicable*

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Picture 2 showing trees that require cutting, if applicable*

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Picture 3 showing trees that require cutting, if applicable*

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Signature*

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