Form CEM-5819A "Cable Verification Worksheet" - California

What Is Form CEM-5819A?

This is a legal form that was released by the California Department of Transportation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2018;
  • The latest edition provided by the California Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CEM-5819A by clicking the link below or browse more documents and templates provided by the California Department of Transportation.

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Download Form CEM-5819A "Cable Verification Worksheet" - California

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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CABLE VERIFICATION WORKSHEET
CEM-5819A (NEW 09/2018)
Page 1 of 2
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
CONTRACTOR NAME
CERTIFIED FIBER OPTIC TECHNICIAN
Certificate Number
Date Issued
Expiration Date
CERTIFIED FIBER OPTIC TECHNICIAN (Print Name)
SIGNATURE
DATE
Cable Number
Total Number of Fibers
Cable Length from OTDR (km)
UPON ARRIVAL TO JOB SITE
Calculated
105% Shipping Record
Calculated Attenuation =
Attenuation <
Measure Attenuation
Attenuation(dB/km) =
Measured (dB)/Cable Length
105% Shipping
(dB)
(Shipping Record Attenuation) X
from OTDR (km)
Record
(1.05) (dB/km)
Attenuation?
+ Buffer Tube
Wavelength
Wavelength
Wavelength
- Buffer Tube
1310nm
1550nm
1310nm
1550nm
1310nm
1550nm
Fiber Test Results
Buffer Tube
1 Blue
Pass
Fail
2 Orange
Pass
Fail
3 Green
Pass
Fail
4 Brown
Pass
Fail
5 Slate
Pass
Fail
6 White
Pass
Fail
7 Red
Pass
Fail
8 Black
Pass
Fail
9 Yellow
Pass
Fail
10 Violet
Pass
Fail
11 Rose
Pass
Fail
12 Aqua
Pass
Fail
RESIDENT ENGINEER REVIEW
Cable OTDR Test Results
List any Anomaly
Pass
Fail
RESIDENT ENGINEER (Print Name)
SIGNATURE
DATE
COPY TO TRAFFIC OPERATIONS (Print Name)
SIGNATURE
DATE
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CABLE VERIFICATION WORKSHEET
CEM-5819A (NEW 09/2018)
Page 1 of 2
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
CONTRACTOR NAME
CERTIFIED FIBER OPTIC TECHNICIAN
Certificate Number
Date Issued
Expiration Date
CERTIFIED FIBER OPTIC TECHNICIAN (Print Name)
SIGNATURE
DATE
Cable Number
Total Number of Fibers
Cable Length from OTDR (km)
UPON ARRIVAL TO JOB SITE
Calculated
105% Shipping Record
Calculated Attenuation =
Attenuation <
Measure Attenuation
Attenuation(dB/km) =
Measured (dB)/Cable Length
105% Shipping
(dB)
(Shipping Record Attenuation) X
from OTDR (km)
Record
(1.05) (dB/km)
Attenuation?
+ Buffer Tube
Wavelength
Wavelength
Wavelength
- Buffer Tube
1310nm
1550nm
1310nm
1550nm
1310nm
1550nm
Fiber Test Results
Buffer Tube
1 Blue
Pass
Fail
2 Orange
Pass
Fail
3 Green
Pass
Fail
4 Brown
Pass
Fail
5 Slate
Pass
Fail
6 White
Pass
Fail
7 Red
Pass
Fail
8 Black
Pass
Fail
9 Yellow
Pass
Fail
10 Violet
Pass
Fail
11 Rose
Pass
Fail
12 Aqua
Pass
Fail
RESIDENT ENGINEER REVIEW
Cable OTDR Test Results
List any Anomaly
Pass
Fail
RESIDENT ENGINEER (Print Name)
SIGNATURE
DATE
COPY TO TRAFFIC OPERATIONS (Print Name)
SIGNATURE
DATE
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CABLE VERIFICATION WORKSHEET
Page 2 of 2
CEM-5819A (NEW 09/2018)
GENERAL INFORMATION
This form is to provide documentation that individual fibers in the fiber optic cables are in compliance with the specification upon arrival to
the job site.
FORM
Complete the form for each spool of fiber optic cable that arrives to the job site and ensure individual fibers in the cable comply with the
specifications. This form includes multiple pages. Complete a table for every buffer tube in the cable (two (2) per page). Provide a copy of
the completed form to the engineer.
CONTRACT NUMBER/CO/RTE/PM: For local agency encroachment permit projects, write the encroachment permit number in the
CONTRACT NUMBER field.
PROJECT IDENTIFICATION NUMBER: For local agency encroachment permit projects, write N/A in the field.
CONTRACTOR NAME: Write the name of the contractor or subcontractor installing the fiber optic cables.
CERTIFIED FIBER OPTIC TECHNICIAN: Enter the certification information for the employee performing the fiber optic tests.
Certificate Number: Enter the certificate number.
Date Issued: Write the date issued.
Expiration Date: Write the certificate expiration date.
Cable Number: Enter the cable number obtained from cable reel label.
Total Number of Fibers: Enter the total number of fibers in the cable.
Cable Length: Enter the total cable length measured by the OTDR in kilometers. If length is measured in feet, divide it by 3,280.84.
Buffer Tube: Use the drop down box to select the number and color of the buffer tube containing the fiber being tested.
Buffer Tube: Use the +/- Buffer Tube buttons to add or subtract buffer tubes (tables) as needed.
Measured Attenuation: Enter the attenuation value (dB) measured by the OTDR for both wavelengths 1310nm and 1550nm.
Calculate Attenuation: Divide the measured attenuation (dB) by the cable length (km) and enter the result. Repeat the calculations for
both wavelength, 1310nm and 1550nm. If length is measured in feet, divide length by 3,280.84.
105% Shipping Record Attenuation: Multiply the attenuation value obtained from the shipping records by 1.05 and enter the result.
Repeat the calculation for both wavelength, 1310nm and 1550nm.
Calculated Attenuation < 105% Shipping Record Attenuation: Compare the calculated attenuation to the 105% shipping record
attenuation. If the calculated attenuation is less than the 105% shipping records attenuation, select "pass" to note the individual fiber
meets the attenuation requirements, otherwise select "fail" to note the individual fiber does not meet the attenuation requirements.
Cable OTDR Test Results: Verify all fibers meet the attenuation requirements and select "pass," if at least one of the fibers failed the
test, select "fail."
List any anomaly: Enter additional information, why the fiber optic cable does not meet the requirements.
ATTENUATION COMPLIANCE
The engineer inspecting the fiber optic installation must:
Review the completed form and verify the fiber optic cable complies with the attenuation requirements before authorizing installation of
the cable.
Reject the fiber optic cable, if at least one of the fibers does not comply with the attenuation requirements. The spool of fiber optic cable
must be replaced, if rejected.
Inform the contractor of the requirements to test the replacement cable.
Have a representative from the District Traffic Operations office to complete the name, sign, and date.
Provide a copy of the signed form to the District Traffic Operations representative and file a copy in Category 58.
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
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