Telecom Site Survey

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and easy way to document locational, electrical, cabling, network considerations and more. Find the
digital version of this form and more at https://www.fulcrumapp.com/apps/telecom-site-survey.

General Information
Customer Name

Organization

Change Forecast

Project Name

Deliverable Name

Date Last Surveyed Date Time

Reference Number

Photo

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 Site Details
What is the site
location?

What is the site Name?

What is the site CLLI/
code?
What is the site
address? Street Address

City, State, Zip

What is the shipping
address?
If different from above. Street Address

City, State, Zip

Who is the site contact?

Name

Title

Telephone

Mobile

Fax

Email
Out of hours contact
information

Is this site owned and maintained by the customer?

☐ Yes ☐ No

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 Who?

Is this a manned site?

☐ Yes ☐ No
What are the hours of operation?

What is the number of the telephone nearest to the Network equipment

and its location?

What are the building and room access procedures? For example, must visiting
personnel be escorted by customer personnel?

Are there any special security/safety procedures? Such as safety glasses, safety
shoes, and hard hat areas

☐ Yes ☐ No

What is the name and number of the site coordinator who is responsible
for ensuring that the site is prepared adequately for the installation of the
Network equipment?

Name

Number

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 What will the cabinet location be?

Floor

Room

Position

Electrical Considerations
Is the correct AC power source available?
☐ Yes ☐ No
Voltage range

Location Street Address

City, State, Zip

Is the correct DC power source available?

☐ Yes ☐ No
Voltage range

Location Street Address

City, State, Zip

Will the Network equipment be powered from a UPS (AC) or battery

backup (DC)?
☐ Yes ☐ No
UPS/Battery

Does the backup power source have sufficient capacity for this new
equipment?
☐ Yes ☐ No
Capacity

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 Does this site have additional backup from generator power?
☐ Yes ☐ No
Details

Are there any restrictions as to when the Network equipment might be

powered up?
☐ Yes ☐ No
Are there any 240v AC outlets available within 2m of the Network
equipment for peripheral equipment?
☐ Yes ☐ No
How many

Distance

Location Street Address

City, State, Zip

Is there an isolated earth point available close to the Network equipment

position?
☐ Yes ☐ No
Distance

Location Street Address

City, State, Zip

What is the agreed plan to rectify any outstanding points from this
section and any notes or special comments for the implementation team?

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 Cabling

Has the cable schedule from the SRS document been discussed, and
does the customer understand/agree with the requirements?
☐ Yes ☐ No
Are cables that are external to the cabinets to be installed?
Such as rack to rack, DDF to patch panel

☐ Yes ☐ No
Cable run length m

Cable run route

Are external cabling lengths within the distances required by the

equipment to avoid signal degradation?
☐ Yes ☐ No
Max cable length m

Where Network will be installing cables that are external to the cabinets,
are there restrictions on when cables might be pulled over cable trays or
under the floor?
☐ Yes ☐ No
Details

Do local fire codes stipulate that special cables are mandatory?

☐ Yes ☐ No
Cable spec

Are additional overhead cable trays, drop posts, or other trunking

required to install the Network equipment?
☐ Yes ☐ No
Responsible party

Completion date Date Time

Details

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 Is there sufficient clearance under overhead cable trays?
☐ Yes ☐ No
Clearance mm

If a raised floor exists, is sufficient space available for routing cables?

☐ Yes ☐ No
Depth of space mm

What is the agreed plan to rectify any outstanding points from this
section and any notes or special comments for the implementation team?

Network Synchronization
Is an external clock source present at this site?
☐ Yes ☐ No

If yes, what level of STRATUM accuracy does it conform to?

STRATUM level

Location Street Address

City, State, Zip

Details

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 Are there other Building Integrated Timing Sources configured
at this site?
☐ Yes ☐ No
Location Street Address

City, State, Zip

Details

If the clock source has yet to be implemented, what is the due date for its
completion?

Have primary and secondary timing connection assignments for

the Network equipment been reserved?
☐ Yes ☐ No
What is the agreed plan to rectify any outstanding points from this
section and any notes or special comments for the implementation team?

Carrier Circuits
What is the physical presentation of the Network circuits? e.g. E3 with 75ohm
BNC, T3 with Type 43, STM-1 with single-mode fibre and SC connector

Destination
Description

Destination Street Address

City, State, Zip

Circuit

Type/Presentation

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 If Network circuits are to be presented via a DDF, what are the
termination block identifiers for both the Network circuits and the cables
that connect to the Network equipment?
Such as frame ID, horizontal/vertical locator, termination ID

Destination Street Address

City, State, Zip

Carrier Circuit DDF

Termination Block ID
Network Equipment
DDF Termination
Block ID

What is the agreed plan to rectify any outstanding points from this
section, and any notes or special comments for the implementation team?

Peripheral Data Communications Equipment

(Cont’d)
What is the agreed plan to rectify any outstanding points from this
section, and any notes or special comments for the implementation team?

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 Peripheral Voice Communications Equipment
(Cont’d)
If PBX circuits are to be presented via a DDF, what are the termination
block identifiers for both the PBX circuits and the cables that connect to
the Network equipment?
Such as frame ID, horizontal/vertical locator, termination ID

Detail the PBX primary and secondary clock sources as currently

configure

What is the agreed plan to rectify outstanding points from this section, as
well as any notes or special comments for the implementation team?

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 Site Survey Completion
Certificate type

System description

Document version

Signature

Name

Customer

Network Systems Signature

Date Date Time

Signature

Customer Signature
Date Date Time

Signature

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