Cincinnati Bell Telephone Work Authorization Clearance Program

Job Site Authorization Form

Page 1 of 5

TO FILL IN AN ONLINE FORM

Use the following methods to move among the fill-in form fields

To / Press
Enter data in a field / Type in enabled fields (example: )
Move to the next field / TAB or ENTER or the DOWN ARROW key
Move to a previous field / SHIFT+TAB or the UP ARROW key
Select or clear a check box / SPACEBAR or X
Insert a tab character in a form field / CTRL+TAB
Enter dates (m-d-yy) / Type month –(dash) day –(dash) year

INDEX

PART 1 Collocator / Contractor / Project Information

PART 1AAuthorization and Approval of this Job Site
Authorization Form

PART 2 CBT Job Review and Comments

PART 2A Cincinnati Bell Telephone Approval of this
Job Site Authorization Form

PART 3 EMERGENCY CONTACT LIST

PART 1

Collocator / Contractor / Project Information

1 /

CLLI / Job Name

(Enter CLLI Code) / (Enter Job Name If Applicable)
2 /

Entity Representing

(Enter Collocator Company Name)
3 / Contractor(s) Company
(Enter Name Of Company Who Is Performing The Physical Work)
4 / CBT Project Engineer or Manager
(DO NOT ENTER - CBT Internal Use Only)
5 /

Duration of Job

Estimated Begin Date (m-d-yy) / Estimated End Date (m-d-yy)
6 /

Hours of Work

/ 24x7 / Normal Business Hours / Both
(Check ONLY ONE Box)
7 /

The Entity for who this work is performed requires a Job Walk Through

/ YES
NO
8 /

The Contractor performing this work requires a Job Walk Through

/ YES
NO

Complete the following after walk through

Date Completed (m-d-yy)

Walk Through Participants – Name

Company

1
2
3
4
5
6
9 /

Job Instructions/Description

/ (Enter a brief description of the work to be performed, detailed information must be submitted on a MOP)
9a
9b
9c
9d
9e
10 /

Will any work to be done in or around power equipment?

/ YES
NO

(If the answer to 10 is YES attach instructions and/or procedures that will be used to protect the equipment and your employees.)

PART 1A

Authorization and Approval of this Job Site Authorization Form

For Collocator

Name (Print)

Signature

/ Date (m-d-yy)

For Contractor

Name(Print)

Signature

/ Date (m-d-yy)

PART 2

CBT Job Review and Comments

(FOR CBT USE ONLY)

1 /

CBT requires the entity doing this work to perform a Job Walk Through

/ YES
NO
2 /

Complete (Part 3) EMERGENCY CONTACT LIST

3 /

I have completed CBT section of (Part 3) the EMERGENCY CONTACT LIST

/ YES
4 /

CBT Comments

4a
4b
4c
4d

PART 2A

Cincinnati Bell Telephone Approval of this Job Site Authorization Form

For Cincinnati Bell Telephone

Engineer / Manager

Name (Print)

Signature

/ Date (m-d-yy)

Central Office Manager

Name (Print)

Signature

/ Date (m-d-yy)

PART 3

EMERGENCY CONTACT LIST

CINCINNATI BELL TELEPHONE

24x7 Emergency Contact Number / Primary / 513 – 566-3000
Secondary
Person Responsible for Job Authorization Form / Technical Support for Job Authorization Form

Name (Print)

Phone

Cell Phone

Pager

COLLOCATOR

Company Name

24x7 Emergency Contact Number / (Area Code + Number)
Person Responsible for Job Authorization Form / Technical Support for Job Authorization Form

Name (Print)

Phone

Cell Phone

Pager

CONTRACTOR

Company Name

24x7 Emergency Contact Number / (Area Code + Number)
Person Responsible for Job Authorization Form / Technical Support for Job Authorization Form

Name (Print)

Phone

Cell Phone

Pager

*******************************************************************************************************************

While performing contractual work on any Cincinnati Bell Telephone premise this fully executed form is required to be on the job site and readily available to the contractor and CBT personnel at all times. If at anytime the contractor performing this work cannot provide this completely executed form, or if this form is not on site the contractor may be immediately asked to leave the premise.

*******************************************************************************************************************

7100Cincinnati Bell Telephone - Proprietary