Fillable Massachusetts Department of Transport Qualified Traffic Control Equipment Submission Form for Miscellaneous Temporary Traffic Control Devices

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Massachusetts Department of Transport Qualified Traffic Control Equipment Submission Form for Miscellaneous Temporary Traffic Control Devices

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Qualified Traffic Control Equipment Submission Form for
Miscellaneous Temporary Traffic Control Devices
Submission Instructions: Please submit one application per product. Catalogue cuts shall be included as
attachments. FHWA Federal-aid eligibility letters, if applicable, shall be included with submittal. Other testing
results or certifications which may assist in evaluation may also be included. All equipment shall comply with the
latest edition of Section 850 - Traffic Controls for Construction and Maintenance Operations of the Standard
Specifications, including Supplemental and Interim editions. Upon evaluation MassDOT Highway Division will
contact you.
Part A. Applicant Information
Today's Date
Name
Company
Address
City, State ZIP
Phone
Email
Part B. Basic Product Information
N
ame or Model #
Description
Link to product cutsheet
Product Type
Temporary Sign Stand Portable Traffic Signal
Type III Barricade Temporary Overlay Marker
Other:
Part C. Technical Product Information
Technical Notes (if necessary):
Application Revision: November 14, 2014 Temporary Traffic Control Application
Qualified Traffic Control Equipment: http://goo.gl/OS7o5N Page 1 of 3
Application Revision: November 14, 2014
Qualified Traffic Control Equipment:
http://goo.gl/OS7o5N
Temporary Traffic Control Application
Page 2 of 3
Please complete this section, if applicable.
Test Level n/a TL-2 TL-3 TL-4 TL-5
Methodology NCHRP 350 Manual for Assessing Safety Hardware
FHWA Acceptance Letter(s):
FHWA Limits on Use
Part D. Product Use
H
as this product, or one similar, been previously submitted to MassDOT? Yes No
If Yes, please explain:
Is this a replacement product for one currently approved by MassDOT? Yes No
If Yes, please explain:
Is this product currently in use in Massachusetts? Yes No
If Yes, please explain:
State DOTs that have
approved this product:
Is this product in commercial production? Yes No
If Yes, for how long?
If No, please explain:
Have there been any recalls on this product? Yes No
If Yes, please explain:
Recommended Routine Maintenance Program (if applicable):
Warranty Information:
Part E. Contact Information
Supplier/
Distributer
Contact Title
Company
Website
Address City, State ZIP
Email Phone
Manufacturer
Contact Title
Company
Website
Address City, State ZIP
Email Phone
Reference #1
Contact Title
Agency
Email Phone
Reference #2
Contact Title
Agency
Email Phone
(This space may be used to provide additional information)
Applications may be submitted to james.danila@dot.state.ma.us or by mail to:
Jim Danila, P.E., Assistant State Traffic Engineer
Traffic and Safety Engineering Section, MassDOT Highway Division
10 Park Plaza, Room 7210
Boston, MA 02116
Application Revision: November 14, 2014 Temporary Traffic Control Application
Qualified Traffic Control Equipment: http://goo.gl/OS7o5N Page 3 of 3
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Massachusetts Department of Transport Qualified Traffic Control Equipment Submission Form for Miscellaneous Temporary Traffic Control Devices

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Completed 13 May 2020

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