Utility Pole Loading Survey Form
Use this form to record utility pole loading conditions, attached equipment, measurements, observations, and recommended follow-up actions.
Surveyor and Site Identification
Survey Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Surveyor Name
*
First Name
Middle Name
Last Name
Company / Utility Organization
*
Work Order / Survey Reference Number
Utility Pole ID / Asset Tag
*
Survey Location / Address or GPS Coordinates
*
Pole and Attachment Details
Pole Material
*
Wood
Concrete
Steel
Composite
Other
Pole Height (ft)
*
Pole Class / Rating
Approximate Installation Year or Age
Attachment Inventory
*
Loading Condition Assessment
Current loading condition
*
Underloaded
Acceptable
Near limit
Overloaded
Visual signs of stress or lean
*
Yes
No
Notes on stress or lean
Observed pole deflection or damage
*
Yes
No
Notes on deflection or damage
Attachment clearance or spacing concerns
*
Yes
No
Overall structural concern rating
*
1
2
3
4
5
Measurements and Observations
Pole lean angle (degrees)
Pole lean direction
Approximate ground clearance issue (feet)
Conductor or attachment height notes
Weather, ground, and site conditions at time of inspection
Please Select
Clear
Cloudy
Rainy
Windy
Wet ground
Snow/Ice
Uneven terrain
Other
Additional remarks from inspector
Supporting Evidence and Follow-up
Supporting Photos or Site Images
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Recommended Action / Status
*
Please Select
No action needed
Monitor
Engineer review
Restring/Rebalance
Repair
Replace
Other
Urgency / Priority
*
Please Select
Low
Medium
High
Critical
Follow-up Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Survey
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