TE-401 (8-11)

PREVENTATIVE MAINTENANCE REPORT

CLOSED CIRCUIT TELEVISION CAMERA
PLEASE TYPE OR PRINT IN BLUE OR BLACK INK ALL INFORMATION www.dot.state.pa.us

DEVICE TYPE: DISTRICT ID: STATEWIDE ID:

DATE (mm/dd/yyyy): TIME: COUNTY: SERIAL/RFID NUMBER:

STATE ROUTE (S.R.): DIRECTION:

LOCATION (Mile Marker/Segment-Offset):

VERIFIED AT SITE: YES NO
LATITUDE/LONGITUDE:

TIME ARRIVING AT SITE: TIME LEAVING SITE:

DESCRIPTION OF PROBLEM(S):

CORRECTIVE ACTIONS TAKEN:

PROBLEM(S) CORRECTED: YES NO

PARTS:

LABOR/EQUIPMENT/TRAFFIC CONTROL:

ADDITIONAL COMMENTS:

By signing below, the signee confirms that all four preventative maintenance checklists (General, Device, Cabinet, and Communications
and Electrical Service) and the ITS Structures Preventative Maintenance Guide have been completed, and that all checklist items receiving
a rating of Fair or Poor have been reported above.

Printed Name Signature

Date (mm/dd/yyyy) Company

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DISTRICT ID:_________________________________________ STATEWIDE ID:____________________________________ DATE:__________________ TIME:__________________

CLOSED CIRCUIT TELEVISION CAMERA

General Checklist
TASK # TASK COMPLETED? CONDITION (Select One)

G001 Check clearance of tree branches or brush around power Excellent

and communication lines. Report required tree trimming YES
Good
and/or brush clearing work. NO
Fair*
N/A
Poor*
G002 Check that CCTV system is adequately protected by Excellent
guiderail. Report damaged guiderail. YES
Good
NO
Fair*
N/A
Poor*

G003 Check for damage (lightning, leaning, car impacts, Excellent
vandalism, etc.). Repair as necessary. YES
Good
NO
Fair*
N/A
Poor*
G004 Verify that the ITS site plans, ITS system block diagrams, Excellent
electrical details/wiring diagram, and any other necessary YES
Good
records are located in the cabinet. NO
Fair*
N/A
Poor*

*Document all Fair/Poor results in the Preventative Maintenance Report Form. Repair where possible.
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DISTRICT ID:_________________________________________ STATEWIDE ID:____________________________________ DATE:__________________ TIME:__________________

CLOSED CIRCUIT TELEVISION CAMERA

Device Checklist
TASK # TASK COMPLETED? CONDITION (Select One)

D001 Perform preventative maintenance in accordance with the YES Excellent

manufacturer's recommendations and as follows: Good
NO
N/A Fair*
Poor*
D002 Check for proper clearance of tree branches or brush; Excellent
schedule any required trim work. YES
Good
NO
Fair*
N/A
Poor*

D003 Inspect for general condition, wear, rust, cracks, loose Excellent
connections, frayed cables, and damage caused by YES
Good
(lightning, weather, car impacts, vandalism, etc.). Repair NO
Fair*
as necessary. N/A
Poor*
D004 Inspect camera housings for wear, rust, cracks, loose Excellent
connections, and frayed cables. Repair/replace as YES
Good
necessary. NO
Fair*
N/A
Poor*
D005 Note and replace any missing, damaged, rusted, cracked, Excellent
or bent parts. YES
Good
NO
Fair*
N/A
Poor*
D006 Inspect mounting hardware (anchor bolts, pole Excellent
attachment) for rust, cracks, etc. Repair/replace as YES
Good
necessary. NO
Fair*
N/A
Poor*
D007 Check camera alignment (for barrel cameras only). Excellent
YES
Good
NO
Fair*
N/A
Poor*
D008 Visually inspect all camera equipment for wear and Excellent
corrosion. Replace substandard equipment. YES
Good
NO
Fair*
N/A
Poor*
D009 Inspect enclosure window and lens. Clean glass with Excellent
suitable glass cleaning agent in/out. YES
Good
NO
Fair*
N/A
Poor*
D010 Operate PTZ (Pan-Tilt-Zoom) for all functions to their Excellent
extreme limits to ensure full operation and proper focus/ YES
Good
zoom functions. NO
Fair*
N/A
Poor*

(checklist continued on next page)

*Document all Fair/Poor results in the Preventative Maintenance Report Form. Repair where possible.
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DISTRICT ID:_________________________________________ STATEWIDE ID:____________________________________ DATE:__________________ TIME:__________________

CLOSED CIRCUIT TELEVISION CAMERA

Device Checklist
TASK # TASK COMPLETED? CONDITION (Select One)

D011 Check operation of auto-iris and adjust for correct YES Excellent
operation per operational and maintenance manual. Good
NO
N/A Fair*
Poor*
D012 Check for tightness of all internal hardware. Excellent
YES
Good
NO
Fair*
N/A
Poor*

D013 Inspect all wiring harnesses and interconnecting cable Excellent
assemblies/connectors for tightness, wear, and corrosion. YES
Good
Correct as required. NO
Fair*
N/A
Poor*
D014 Check camera housing pressure (typically 5psi +/- 1psi). Excellent
Pressurize per Manufacturer's Instructions if not within YES
Good
limits and document readings on the maintenance report NO
Fair*
form. N/A
Poor*
D015 Visually inspect all exposed grounding systems at the Excellent
device for corrosion and damage. YES
Good
NO
Fair*
N/A
Poor*

PERFORM THE FOLLOWING FOR THE CAMERA

LOWERING DEVICE (CLD) COMPLETED? CONDITION (Select One)
Excellent
D016 Perform preventative maintenance in accordance with the YES
manufactures recommendations and as follows: Good
NO
Fair*
N/A
Poor*
Excellent
D017 Verify that CLD cables are not stressed while camera is YES
locked at top of pole. Good
NO
Fair*
N/A
Poor*
Excellent
D018 Lower camera per manufacturer's instructions. Verify that YES
Good
the camera lowers without difficulty, and can be locked at NO
any point in the lowering process (including ground level). Fair*
N/A
Poor*
Excellent
D019 Visually inspect electrical and mechanical connections of YES
Good
camera housing for wear, corrosion, weather damage, and NO
any other damage. Repair/replace where necessary. Fair*
N/A
Poor*

(checklist continued on next page)

*Document all Fair/Poor results in the Preventative Maintenance Report Form. Repair where possible.
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DISTRICT ID:_________________________________________ STATEWIDE ID:____________________________________ DATE:__________________ TIME:__________________

CLOSED CIRCUIT TELEVISION CAMERA

Device Checklist
TASK # TASK COMPLETED? CONDITION (Select One)

D020 Visually inspect CLD cable for frays, elongation, and YES Excellent
corrosion (where visible). Good
NO
N/A Fair*
Poor*
D021 Return the camera to the top of the pole using the Excellent
CLD. Verify that the camera locks into place and, upon YES
Good
reconnection, fully re-starts without manual initiation. NO
Fair*
N/A
Poor*

D022 Lubricate lock/crank assembly with an acceptable Excellent
lubricant (per manufacturer's recommendations). YES
Good
NO
Fair*
N/A
Poor*

*Document all Fair/Poor results in the Preventative Maintenance Report Form. Repair where possible.
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DISTRICT ID:_________________________________________ STATEWIDE ID:____________________________________ DATE:__________________ TIME:__________________

CLOSED CIRCUIT TELEVISION CAMERA

Device Checklist
TASK # TASK COMPLETED? CONDITION (Select One)

C001 Check the condition of surface and general cabinet YES Excellent
appearance for damage (paint, damage, and graffiti). Good
NO
N/A Fair*
Poor*
C002 Check cabinet door and locking mechanism for proper Excellent
closure. Adjust or repair if needed. Lubricate hinges and YES
Good
lock. NO
Fair*
N/A
Poor*

C003 Inspect and change filters where applicable. Excellent
YES
Good
NO
Fair*
N/A
Poor*
C004 Check weatherproof seal (gasket). Excellent
YES
Good
NO
Fair*
N/A
Poor*
C005 Remove any snow or brush from doorway opening or area Excellent
surrounding cabinet. YES
Good
NO
Fair*
N/A
Poor*
C006 Inspect cabinet mounting hardware (anchor bolts, pole Excellent
attachment) for rust, cracks, etc. Tighten if necessary. YES
Good
NO
Fair*
N/A
Poor*
C007 Check for water accumulations and duct sealant. Excellent
YES
Good
NO
Fair*
N/A
Poor*
C008 Clean and vacuum inside of cabinet and equipment to Excellent
remove dust. YES
Good
NO
Fair*
N/A
Poor*
C009 Check light bulbs and replace where applicable. Excellent
YES
Good
NO
Fair*
N/A
Poor*
C010 Check and inspect equipment racks/shelves (tighten any Excellent
lose hardware). YES
Good
NO
Fair*
N/A
Poor*

(checklist continued on next page)

*Document all Fair/Poor results in the Preventative Maintenance Report Form. Repair where possible.
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DISTRICT ID:_________________________________________ STATEWIDE ID:____________________________________ DATE:__________________ TIME:__________________

CLOSED CIRCUIT TELEVISION CAMERA

Device Checklist
TASK # TASK COMPLETED? CONDITION (Select One)

C011 Check operation of fan/air conditioner unit and heater, YES Excellent
and replace where applicable. Good
NO
N/A Fair*
Poor*
C012 Check radio interference filter (RFI) and lightning arrestor. Excellent
YES
Good
NO
Fair*
N/A
Poor*

C013 Check circuit breaker and fuses. Excellent
YES
Good
NO
Fair*
N/A
Poor*
C014 Check ground fault receptacle. Excellent
YES
Good
NO
Fair*
N/A
Poor*
C015 Check environmental systems. Excellent
YES
Good
NO
Fair*
N/A
Poor*
C016 Check the controller and associated units, indicator Excellent
lights. YES
Good
NO
Fair*
N/A
Poor*
C017 Inspect all connections, cabling, and physical appearance Excellent
of the equipment within the cabinets. YES
Good
NO
Fair*
N/A
Poor*
C018 Ensure that cables are not stressed. Excellent
YES
Good
NO
Fair*
N/A
Poor*
C019 Hand-tighten all electrical terminations as necessary. Excellent
YES
Good
NO
Fair*
N/A
Poor*
C020 Check and inspect controller. Run and save controller Excellent
diagnostics according to manufacturer’s specifications. YES
Good
NO
Fair*
N/A
Poor*

(checklist continued on next page)

*Document all Fair/Poor results in the Preventative Maintenance Report Form. Repair where possible.
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DISTRICT ID:_________________________________________ STATEWIDE ID:____________________________________ DATE:__________________ TIME:__________________

CLOSED CIRCUIT TELEVISION CAMERA

Device Checklist
TASK # TASK COMPLETED? CONDITION (Select One)

C021 Inspect all wires for loose connections, frayed wires, YES Excellent
rodent damage, etc. Repair as necessary. Good
NO
N/A Fair*
Poor*
C022 Check incoming power for proper voltage and correct if Excellent
not within tolerances. YES
Good
NO
Fair*
N/A
Poor*

C023 Check function and communications (modem). Excellent
YES
Good
NO
Fair*
N/A
Poor*
C024 Visually inspect all exposed grounding systems at the Excellent
device for corrosion and damage. YES
Good
NO
Fair*
N/A
Poor*
C025 Check conduit entry to cabinet. Provide duct sealant (or Excellent
another means) to prevent rodent entry if not already YES
Good
present. NO
Fair*
N/A
Poor*

PERFORM THE FOLLOWING FOR LOCATIONS WITH

UNINTERRUPTIBLE POWER SUPPLY (UPS): COMPLETED? CONDITION (Select One)

C026 Visually inspect general condition of UPS for corrosion, Excellent

YES
wear, and any other damage. Repair as needed. Good
NO
Fair*
N/A
Poor*
C027 Clean UPS and battery. Excellent
YES
Good
NO
Fair*
N/A
Poor*
C028 Check all battery terminal connections for security and Excellent
YES
apply corrosion preventative compound. Tighten as Good
NO
necessary. Fair*
N/A
Poor*

C029 Verify functionality of UPS by disconnecting power at Excellent

breaker. Verify that UPS maintains operation. YES
Good
NO
Fair*
N/A
Poor*

*Document all Fair/Poor results in the Preventative Maintenance Report Form. Repair where possible.
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DISTRICT ID:_________________________________________ STATEWIDE ID:____________________________________ DATE:__________________ TIME:__________________

CLOSED CIRCUIT TELEVISION CAMERA

Device Checklist
TASK # TASK COMPLETED? CONDITION (Select One)

E001 Check to be sure hand hole covers are secure. Tighten if YES Excellent
necessary. Good
NO
N/A Fair*
Poor*
E002 Check pull boxes (damage, covers missing, or damaged). Excellent
Repair if necessary. YES
Good
NO
Fair*
N/A
Poor*

E003 Check conduit entry to junction box. Repair if necessary. Excellent
YES
Good
NO
Fair*
N/A
Poor*
E004 Check conduit runs for settling of trench. Excellent
YES
Good
NO
Fair*
N/A
Poor*
E005 Pump junction box dry if water is present remove. Excellent
YES
Good
NO
Fair*
N/A
Poor*
E006 Clean garbage from junction box. Excellent
YES
Good
NO
Fair*
N/A
Poor*
E007 Visually inspect lugs for burning corrosion, water Excellent
infiltration and rodent damage. YES
Good
NO
Fair*
N/A
Poor*
E008 Visually inspect cable tags. Replace or reattach if needed. Excellent
YES
Good
NO
Fair*
N/A
Poor*
E009 Visually inspect bushings for rust or damage. Excellent
YES
Good
NO
Fair*
N/A
Poor*
E010 Visually inspect splice kit for integrity and water Excellent
infiltration. Repair or replace if necessary. YES
Good
NO
Fair*
N/A
Poor*

(checklist continued on next page)

*Document all Fair/Poor results in the Preventative Maintenance Report Form. Repair where possible.
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DISTRICT ID:_________________________________________ STATEWIDE ID:____________________________________ DATE:__________________ TIME:__________________

CLOSED CIRCUIT TELEVISION CAMERA

Device Checklist
TASK # TASK COMPLETED? CONDITION (Select One)

E011 Inspect all equipment grounding conductors and YES Excellent

connections for integrity. Good
NO
N/A Fair*
Poor*
E012 Check antenna for proper communications. Excellent
YES
Good
NO
Fair*
N/A
Poor*

E013 Verify communications by having a message displayed Excellent
remotely from the Traffic Operations Center. YES
Good
NO
Fair*
N/A
Poor*

PERFORM THE FOLLOWING FOR LOCATIONS WITH

DIRECT ELECTRICAL CONNECTION: COMPLETED? CONDITION (Select One)
E014 Check meter cabinet/pole/pedestal for damage (lightning, Excellent
YES
leaning, vehicle damage, vandalism, corrosion, etc). Good
NO
Fair*
N/A
Poor*
E015 Check service pole base. Replace base cover and clean Excellent
YES
out if necessary. Good
NO
Fair*
N/A
Poor*

E016 Check cabinet/conduit mounting hardware. Replace bolt Excellent

YES
cover and tighten if necessary. Good
NO
Fair*
N/A
Poor*
E017 Check pole base splices for damage, water infiltration, Excellent
YES
and rodent damage. Good
NO
Fair*
N/A
Poor*
E018 Visually inspect all exposed grounding systems at the Excellent
YES
device for corrosion and damage. Good
NO
Fair*
N/A
Poor*

E019 Visually inspect the meter socket and disconnect for Excellent
damage, vandalism, and missing hardware. YES
Good
NO
Fair*
N/A
Poor*

(checklist continued on next page)

*Document all Fair/Poor results in the Preventative Maintenance Report Form. Repair where possible.
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DISTRICT ID:_________________________________________ STATEWIDE ID:____________________________________ DATE:__________________ TIME:__________________

CLOSED CIRCUIT TELEVISION CAMERA

Device Checklist
TASK # TASK COMPLETED? CONDITION (Select One)

E020 Check anchor bolts for tightness and corrosion. YES Excellent
NO Good
N/A Fair*
Poor*
E021 Check breakers. Excellent
YES
Good
NO
Fair*
N/A
Poor*

E022 Check meter cabinet for damage. Excellent
YES
Good
NO
Fair*
N/A
Poor*
E023 Check meter cabinet locking mechanism. Adjust or repair Excellent
if needed. YES
Good
NO
Fair*
N/A
Poor*

PERFORM THE FOLLOWING FOR LOCATIONS WITH

SOLAR POWER ASSEMBLIES: COMPLETED? CONDITION (Select One)
E024 Using acceptable battery analyzer, perform load test Excellent
YES
and verify passing condition. Good
NO
Fair*
N/A
Poor*
E025 Check batteries; clean and fill as necessary. Excellent
YES
Good
NO
Fair*
N/A
Poor*
E026 Test battery charging system. Excellent
YES
Good
NO
Fair*
N/A
Poor*
E027 Check all battery terminal connections for security and Excellent
YES
apply corrosion preventative compound. Good
NO
Fair*
N/A
Poor*
E028 Thoroughly clean solar panels that power the battery Excellent
packs. YES
Good
NO
Fair*
N/A
Poor*

(checklist continued on next page)

*Document all Fair/Poor results in the Preventative Maintenance Report Form. Repair where possible.
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DISTRICT ID:_________________________________________ STATEWIDE ID:____________________________________ DATE:__________________ TIME:__________________

CLOSED CIRCUIT TELEVISION CAMERA

Device Checklist
TASK # TASK COMPLETED? CONDITION (Select One)

E029 Inspect solar panel assembly for damage. Repair or YES Excellent
replace if necessary. Good
NO
N/A Fair*
Poor*
E030
Verify that solar panels are arranged in such a way as to Excellent
allow panels to receive direct sunlight. Report any issues. YES
Good
NO
Fair*
N/A
Poor*
E031 Check clearance of tree branches or brush around solar Excellent
panel assembly, report required tree trimming and/or YES
Good
brush clearing work. NO
Fair*
N/A
Poor*

*Document all Fair/Poor results in the Preventative Maintenance Report Form. Repair where possible.
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