ALPHA OMEGA RESIDENTIAL SITE REPORT
Copyright 2025 © Electrify EVSE. All rights reserved
CASE NUMBER
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INSTALL TEAM CONTACT INFORMATION
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Any question, Contact 1-888-822-EVSE (3873) / 770-633-0591
SECTION A: SITE INFORMATION
To Field Rep: For Accuracy, please complete prior to scheduled "Site Visit Date"
1a. Site Contact Name (Actual)
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1b. POC Phone Number
1c. Scheduled Appointment Date (MUST)?
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Please Select
Yes - Made an Appointment
N/A - Not Applicable
No - Please explain why (@ comment section)
1d. Scheduled Site Visit Date
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-
Month
-
Day
Year
1f. Verified EV Charger have been delivered to Site ?
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Please Select
Yes
No
No replacements/parts w/ Service required
1e. Scheduled Time
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Must complete Scheduled Time for EVSE to be Ready
AM
PM
AM/PM Option
1g. Have you confirm that EV was available at Site for Charger testing ?
Please Select
Yes-EV Secured at Site by the Client
No - I brought our EV
N/A
1h. Site Address
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SECTION B: SCOPE OF WORK INFORMATION
To Electrician: Complete this section prior to "Site Visit Date"
1a. Electrician Name
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1b. Electrician Email
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*Manager's email which reviews and approves work performed
2. Task Performed (Click All That Applies for Install ONLY. Service is for after service required)
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Install: EV Charger Installation
Install: Electrical Cable Installed
Install: Subpanel
Install: Charger Configuration
Service: Commission
Service: Cord Replacement
Service: Firmware Update
Service: Incoming Power
Service: SIM Card Swap
Service: Troubleshoot
Service: Removal
3. CONFIRM: You have a clear instructions and download(s) for your assignment? (firmware file, etc.)
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Please Select
Yes - I have all related information and files.
No - I do not have clear instruction
4. Scope of Work (Click each for Confirmation of Understanding)
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1. Review the Scope of Work with Customer
2. Scope Installation and Panel Access Areas
3. Verify Correct EV Charger
4. Install EV Charger
5. Connect Proper Cord Length
6. Check for Correct Power In/Out
7. Test Charger EV (15 min)
8. Instruct Customer on Proper Use
9. Clean up the Area (leave the Charger Box)
10. Checkout - Call In
SECTION C: SCOPE OF WORK PERFORMED & OUTCOME
To be Completed @ the Installation Site by Electrician/Technician
1a. EV Charger Installation Status
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Please Select
Yes, Completed - Installed
No, Not Completed - Need to Return
No, POC not available @ the scheduled time
No, EV Charger was not available
No, Emergency and was reschedule by POC
DO NOT SKIP THIS QUESTION: Your Work could be Rejected!
1b. Length of time EV Charged w/ new Charger
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Please Select
10 min - EV Charged
15 min - EV Charged
30 min - EV Charged
EV Charging not performed (No EV Available)
EV Charging not performed (Charger not Charging)
DO NOT SKIP THIS QUESTION: Your Work could be Rejected!
1c. MAJOR Tasks Performed
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Performed (Check to Confirm)
Task Completed?
Review Scope of Work
Yes
No
Scan the Work Area
Yes
No
Install EV Charger
Yes
No
EV Test Charge (15 min minimum)
Yes
No
Instruct Customer
Yes
No
Clean up the Area
Yes
No
1d. If there are any issues please check all that applies and describe in comment section in detail
Charger Not Installed - POC Absent
Charger Not installed - Faulty Charger
Charger Not installed - Electrical Panel Issues
Charger Not installed - Condition dangerous
Charger Not Tested - EV Not Available
Charger not tested - No Electricity
Dangerous site conditions
Weather Issues
Breaker Panel access blocked
Emergencies (describe in section 1.a.)
Other reasons (describe in section 1.a.)
INSTALLATION DETAILS (If new Breaker/Sub-panel Installation Required, MUST BE permitted by Installation Team)
1. EV Charger Manufacturer, Model# and Serial # Installed during Site Visit
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Manufacturer
Model Number
Serial Number
2. If Required, did the Property Owner Obtain City Permit to Install EV Charger?
*
Please Select
Yes - Obtained the Permit
No - Not Obtain Yet
Not Required
DO NOT SKIP THIS QUESTION: Your Work could be Rejected!
3. Actual Location of the Electrical Panel Box
*
Please Select
Basement
Garage
Utility room
Exterior wall (for older homes facing the street)
Other locations: Storage rooms, Entryways, Hallways, Under staircases, Kitchen pantries, and Utility closets.
N/A: Electrical Panel Box Not Reachable
DO NOT SKIP THIS QUESTION: Your Work could be Rejected!
4. Dedicated Circuit per Port
*
Please Select
Yes
No
N/A
DO NOT SKIP THIS QUESTION: Your Work could be Rejected!
5. Actual Length Between Electrical Panel to EV Charger
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Please Select
<= 10ft between Electrical Panel and Charger
10ft < x <= 20ft between Electrical Panel and Charger
20ft < x <= 30ft between Electrical Panel and Charger
30ft < x between Electrical Panel and Charger
Not sure / Unable to Provide Distance
DO NOT SKIP THIS QUESTION: Your Work could be Rejected!
6. Did you PERFORM Test Charge/Show how to Use the Charger?
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Please Select
Yes - Test Charged and Showed how to Use the Charger
Yes - Test Charge Only
Yes - Showed How to Use
No - Customer was not available
No – EV Not Available
Other - Comment below
DO NOT SKIP THIS QUESTION: Your Work could be Rejected!
7. Is New Breaker/Sub-panel required
*
Please Select
Yes
No
N/A
STOP: Call 1-888-822-EVSE (3873) / 770-633-0591
8. Describe Existing Panel's Phase, Voltage and Amperage
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INSTALLATION FOLLOW UP DETAILS
1a. CALL 1-888-822-EVSE (3873) / 770-633-0591 to confirm Connected / Commissioned / Active Charger.
*
Please Select
Yes - Called and Officially Release
Yes - Called but Rep. Not Available
No - Did not called and not officially released
DO NOT SKIP THIS QUESTION: Your Service could be Rejected!
1b. Call in/out Date to be Released
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-
Month
-
Day
Year
1c. Official Check-Out/Release Time
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For Commissioning and Final Session with EVSE for Release Off the Site Minutes Minutes
AM
PM
AM/PM Option
2. Clear Description of the Activities from Your Visit
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3. If you are returning a defective EV Charger, Type in FedEX/UPS Return Pkg # (take a picture and upload to Section D5)
If no Return Pkg Required, TYPE "No Return #"
Section D. Upload Good Quality Pictures
IMPORTANT: THIS SECTION MUST BE COMPLETED by the Electrician/Technician while at the Service Site
1. IMPORTANT FOR ALL INSTALLATION: Pictures of "Installed New EV Charger - 2 close ups and 2 from distance. ****Must Display Clear & Readable Serial Numbers****
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Browse for Pictures
Drag and drop files here
Choose a file
DO NOT SKIP THIS QUESTION: Your Service could be Rejected!
Cancel
of
2. PICTURES OF: a) Breaker, b) Breaker Panel, c) Crimps, and d) Correctly installed electrical cables.
Browse for Pictures
Drag and drop files here
Choose a file
Cancel
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3. IMPORTANT - PICTURES OF THE CHARGER WITH BACKGROUND: OF HOUSE OR GARAGE - 2 Pictures (Wide view)
*
Browse for Pictures
Drag and drop files here
Choose a file
Cancel
of
4. Screen shot of Active Charger Display and with EV being Charged.
*
Browse for Pictures
Drag and drop files here
Choose a file
Cancel
of
5. FEDEX/UPS Return Tracking # Receipt and Other applicable pictures.
Browse for Pictures
Drag and drop files here
Choose a file
Cancel
of
6. POTENTIAL EV/CHARGER MAINTENANCE ISSUE PICTURES - attach any pictures deemed dangerous or needing attention ASAP.
Browse for Pictures
Drag and drop files here
Choose a file
Cancel
of
Signature and Submit Section
IMPORTANT: Signed by electrician/technician who serviced the CASE Ticket(s)
Client/ Site Resident Signature (Use finger of touch screen)
*
Electrician/Technician Signature (Use finger of touch screen)Sign to authenticate information provided
*
Save Entries & Continue Later (Click "Skip Create and Account")
FINAL SUBMISSION
FINAL SUBMISSION
Click to Reset (Clear All Entries)
IMPORTANT NOTICE ON SUBMISSION
"FINAL SUBMISSION": Click this button only to submit the completed Installation Request Form to the Install Team. "SAVE ENTRIES": Use this button to save your progress. DO NOT CREATE AND ACCOUNT. Go to bottom and Click "Skip Create an Account". Or, copy the provided link and send to yourself to complete the survey later. "CLICK TO RESET": This will erase all data and references to previous cases, allowing you to start fresh.
Copyright 2025 © Electrify EVSE. All rights reserved
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