Utility Inspection Form
Inspector Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Inspector Company
Short Name
Licensee Name
Location
Location LS
Location MP
Division
Subdivision
Near City / State
Description of Installation
Inspection Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is this a Cancellation Day?
Yes
No
Construction
Day #
Original # of Days
Current Total Prepaid Days
Prepaid Day Balance
[Total #]-[Day #])
Is project currently projected to overrun paid days?
Yes
No
Contractor / Subcontractor Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Contractor / Sub Company
Hours Worked
Â
Inspector Hours Start & End
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
RWIC Hours Start & End
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Estimate of Man Hours
Â
Worked Man-hours
Hour Minutes
Total Number of Contractor/Personnel
On-Track Protection Details
Â
On-Track Safety Protection Provided By
Type
Form B
Track Warrant
Track & Time
Lookout
Other
Additional Details
Construction Observations
Â
Weather Conditions
Cold
Clear
Snow
High Winds
Wet
Hot
Rain
Sleet
Mud
Other
Daily High/Low Temperature
Time of Safety Briefing
Hour Minutes
Please give information about Briefing Topics covered and # of personnel attendant by companyÂ
Please give information about Contractor / Sub-Contractor personnel & equipment on job site
Did Contractor have personnel during today's activities?
Yes
No
Were all contractor personnel right-of-way Contractor-qualified and badges verified?
Yes
No
N/A
Please give details about work plan for the weekÂ
Please give details about observations, including time of observation
Incident prevention
Provide detail of any action taken to improve worksite safety, clarify safety briefing, and/or prevent future incident(s).
Problems/Irregularities encountered?
Yes
No
Additional Notes
Job site Assessment Audits Completed today?
Yes
No
Worker Assessment Audits were completed for
Project Estimated Percent CompletionÂ
%
Is Construction Complete?
Yes
No
Inspector Email
example@example.com
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