UTS Field Forms

AIA G703

Project Name:

Period To:

Schedule of Values:

Pay Application #:

Contractor:

Architect:

Project Number:

Change Order Request

Project and Contract Information Project Name: Project Number: Project Location: Original Contract Number and Date: Change Order Number: Contractor / Owner / Subcontractor Name(s): Date of Request:

Description of Original Scope

Reason for Change

Detailed Description of Requested Change

Reference Documents

Cost Impact (if known) Material Costs: Labor Costs: Subcontractor Quotes: Equipment or Rentals: Overhead and Markup: Total Estimated Cost Impact:

Schedule Impact

Requested Action Approve and Issue Change Order Authorize Work Pending Formal CO Deny (with explanation) Request Additional Info

Authorization & Signatures Submitted By: Date: Title / Company: Owner / GC Approval: Date: Architect/Engineer (if required):

Corrective & Preventive Action (CAPA)

Issue Description:

Root Cause:

Corrective Actions:

Preventive Actions:

Responsible Person:

Target Completion Date:

Verification of Effectiveness:

Internal Audit Report

Department Audited:

Auditor:

Findings:

Audit Date:

Nonconformities:

Recommendations:

Follow-up Date:

Management Review

Date:

Summary:

Attendees:

Action Items:

Responsible Person:

Next Review Date:

Customer Complaint

Customer Name:

Complaint Details:

Date Received:

Actions Taken:

Resolution Date:

Change Request

Change Description:

Reason:

Requested By:

Date Requested:

Approval Status:

Implementation Date:

Document Control Log

Document Title:

Revision:

Effective Date:

Document Owner:

Next Review Date:

Status:

OSHA 300 Log

Case Number:

Employee Name:

Injury Type:

Job Title:

Date of Injury:

Outcome:

OSHA 300A Summary

Total Injuries:

Lost Work Days:

Total Work Hours:

Year:

Company Name:

Job Safety Analysis (JSA)

Task:

Hazards:

Controls:

PPE Required:

Risk Level:

Responsible Person:

OSHA 301 - Injury and Illness Incident Report

Employee Information Full Name: Home Address: Date of Birth: Gender: Job Title: Immediate Supervisor: Employer Name: Case Number:

Incident Details Date of Injury: Time of Injury: Location of Incident: Describe the Incident: Body Part Affected: Medical Facility (if treated): Physician or Health Care Professional:

Outcome Was the employee hospitalized? Days Away from Work: Days of Job Transfer or Restriction: Date Returned to Work: Was the incident work-related?

Attachments Upload Photos (Max 6):

Confirmation Digital Signature:

Daily Site Log

Project Info Date: Project Name: Project Location:

Weather Weather (Morning): Weather (Afternoon): Temperature Range (°F):

Manpower Total Crew On Site: Subcontractors On Site:

Work Performed Tasks Completed Today: Materials Delivered: Inspections or Tests Performed: Equipment Used:

Site Conditions Delays or Issues: Visitors On Site: Additional Notes: Safety Notes:

Photos and Signatures Upload Photos (Max 6):

Supervisor Name: Digital Signature:

Toolbox Talk

Date:

Topic:

Attendees:

Presenter:

Location:

Summary of Discussion:

Pre-Task Plan

Date:

Scope of Work:

Identified Hazards:

Required PPE:

Responsible Person:

Emergency Action Plan

Location:

Emergency Contacts:

Procedures:

Evacuation Routes:

Assembly Point:

Plan Coordinator:

ISNetworld HSE Evaluation

Evaluator:

Evaluation Date:

Findings:

Score:

Actions Required:

Completion Date:

Customer Information

First Name:

Last Name:

Company:

Job Title:

Email:

Phone:

Address:

Website:

Lead Source:

Notes:

Closet Installation Report

Customer Name:

Installation Date:

Location:

Materials Used:

Installation Notes:

Before Photos:

After Photos: