Fill - Free fillable Flagger Program (Colorado Department of Transportation) PDF form

Revised September 2019

Flagger Program

Quality Assurance

Documentation

For:

(Print or Type Entity Name Here)

(Date of Reporting)

CDOT Flagger Program

Traffic and Safety Engineering Branch

2829 W. Howard Pl.

Denver, Co. 80204

1-888-639-3271

303.757.9219 (Fax)

dot_cdot_flagger@state.co.us

http://www.codot.gov/traffic/lane-close-work-zone-safety

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TABLE OF CONTENTS……………………………………………………1

Instructions…………………….……………………………………………………………...2

Type of Entity…………………………………………………………………………………2

Reporting Entity:

Part I-Required Documentation……………………………………………………………….4

Part II-Training and Testing Information……………………………………………………5-8

Part III-Address and Project Information………………………………………………… 9-10

Part IV-Affirmations/Certification Survey……….……………………………………....11-13

Part V-Recertification Survey….…………………………….................................................14

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INSTRUCTIONS

The purpose of this document is to instruct Certified Entities, who wish to continue

proctorship with CDOT, on how to report Quality Assurance information. This is a required

document. This document is not intended for first time applicants. First time applicants

should download the application from the website listed on the cover page of this sheet.

The Entity is required to maintain all program records for five years, and submit such records

as requested by CDOT. The Entity will make available such records for audit, and maintain a

“student record” for each time an individual is trained. These records shall be open and available

for inspection, by CDOT, during the ‘entities’ regular business hours. Upon request, the Entity

will permit an inspection, by CDOT, of the facilities used for operations and training.

 In Order for an entity to continue proctorship with CDOT, without interruption, the

attached document must be filled in completely. Failure to do so could result in suspension

of the entity’s certification.

 Return a paper version of this document that contains original signatures, and photocopies

or email of the other documents listed in Part I. Do not include blank pages or information

pages. The information pages are for entity use. Contact the branch if you need other

submittal methods.

 All documentation must be returned by the due date listed on the last page of the

application, once yearly, or as requested, until renewal is required. At such time, a new

application for Flagging Certification is required.

TYPE OF ENTITY

Check one of the boxes below to indicate what type of Entity you are. Please give a detailed brief

description of the entity

Private/Small Business Temporary Workforce

Governmental Entity Non-Profit Corrections

School Law Enforcement Other

_____________________________________________________________________________________

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THIS PAGE INTENTIONALLY LEFT BLANK

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PART I: REPORTING ENTITY

Initial the information that has been included.

Required Documentation

 Copy of Designated Custodian/Representative’s current TCS/Flagger

card, if applicable.

 Copy of current TCS or Flagger card for each proctor.

 “Integrity Affidavit”, signed by all proctors. (Pg.7)

 “Affirmations” Form signed by all proctors. (Pg. 11)

 Entity Training Procedures. (Pg.6)

 Reporting Entity Project Information (Pg. 10)

 “Safety Checklist” for the training facility. (Pg.8)

 List/Roster of training dates and names

 Copy of test one (1), two (2), or three (3) for each individual tested by

entity, with pass or fail.

 Copy of Flagger cards for each individual certified by entity.

 “Certification Survey” from all individuals tested. (Pgs.12-13)

 Copy of receipt(s), if participants/flaggers paid for the course.

 Copy of receipt(s) for flagger replacement cards.

 “Recertification Survey”. (Pg. 14)

All addresses applicable to the entity (Pg.#9). This includes:

 Corporate or Parent Company

 Physical and Mailing

 Training

 Project

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PART II: REPORTING ENTITY

Training and Testing

If there is a charge for training and testing, the entity will provide a receipt to CDOT, and to each

student that includes documentation, clearly identifying the price paid by the student.

No charge shall exist to issue the original Flagger card. If there is a charge for a replacement

Flagger card, a receipt shall be issued to CDOT, and each student.

The entity is now required, as of January 2019, to utilize the CDOT Flagger video. No other video

shall be used in lieu of this video.

“Hands On” practical training is now required as part of the four (4) hour course.

An applicant may take test one (1), two (2), or three (3). The Entity will allow an applicant to re-

test if he or she fails the exam. An applicant may take the alternate exam on the same day if he or

she fails it the first time.

An applicant must pass with an 85% percent or better.

Upon passing the test, an applicant shall receive their Original Flagger Certification card within

24 hours.

Entity shall utilize CDOT material and may use supplemental material with one of the listed

platforms: Any other training platforms are subject to verification and must be reported.

 1896 International Municipal Signal Association

o Work Zone Temporary Traffic Control Technician

 1913 National Safety Council-Work Zone Safety

 1969 American Traffic Safety Services Association

o In class Non State Specific Only.

 1970 National Highway Institute-

o In Class Advanced Work Zone Management and Design

 Local Technical Assistance/Tribal Technical Assistance Programs

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PART II: REPORTING ENTITY

Training and Testing (Cont’d)

Explain Entity’s training procedures and list the actual dates of training for the past year or

provide a roster with names and dates. Include the source(s) of, and provide proof of training

that the Entity is using. Use additional sheets if necessary.

_____________________________________________________________________________________

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PART II: REPORTING ENTITY

Proctor Integrity Affidavit

This form is required for all listed proctors. If the entity needs to add proctors, do so with the

Proctor Addition/Deletion Form.

Proctor will:

 Instruct Flagger courses in accordance with the Application and Quality Assurance

Requirements.

 Be present throughout the entire examination process.

 Maintain the confidentiality of the testing materials, exams, and answer keys, by

distributing exam materials immediately prior to the testing session, and collecting all exam

materials immediately afterwards.

 Provide for adequate space for students to test, so as not to allow talking or cheating.

 Answer any questions appropriately and provide information to CDOT if concerns arise

regarding materials.

 Not offer correct answers before all applicants have completed the testing.

I, , agree to follow the

(Proctor Name)

requirements as set forth above in this document.

If evidence of me violating this agreement, or “doctoring” of information is uncovered, I

understand that CDOT has the right to terminate my Entity’s certification.

Signature:

Witness: Date:

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PART II: REPORTING ENTITY

Any date prior to September 1

st

2012 is subject to verification before approval can be granted.

Record additional information about the Entity’s training facility below. Use additional sheets if

necessary.

Initial and record date:

Training Facility Checklist

 Building Code up to date. Last inspected?

 Fire code up to date. Last inspected?

 Working Fire Extinguisher. Date of last inspection and Expiration

date?

 HVAC system up to code. Last inspected?

 Carbon Monoxide Meter(s) present?

 Maximum occupancy for training room?

 ADA Accommodations made?

 Clearly marked exits. More than one escape route in case of emergency.

 Emergency lighting.

 Adequate Classroom lighting.

 Available area for “Hands On” training of flagging techniques.

 Storage is adequate for training materials, such as, Stop sign(s) or

Flagger ahead sign(s).

 “Hands On” training materials are clear of exits and escape routes.

 First Aid Kit available.

_____________________________________________________________________________________

____________________________________________________________________________________

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PART III: REPORTING ENTITY

Address and Project Information

All addresses applicable to the entity. This includes:

 Corporate and/or Parent Company

 Physical and Mailing

 Training

 Project

_____________________________________________________________________________________

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PART III: REPORTING ENTITY

Give details of one (1) project that your Entity was involved in over the past year.

Use additional sheets if necessary

 Start/End Date of Project?

 Was the project a State or Local project?

 Names of Flaggers sent to the project?

 Dates that Flaggers were sent to projects?

 Were those Flaggers used on other projects?

 Did the Entity provide transportation?

 Did the Flagger(s) have to supply their own PPE/or other equipment related to the job?

 Was Flagger’s performance acceptable?

 Were there delays in the project due to Flagger non-compliance?

 Did the Entity replace the Flagger?

 Will the Entity use this Flagger again?

 Did any applicant have to take the exam more than once during a thirty (30) day period?

 Is there any follow up with flaggers regarding re-certification or hiring?

 Attach a sample MHT or TCP drawing.

_____________________________________________________________________________________

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PART IV: AFFIRMATIONS

One form per Entity is required. Original signatures are required from the Designated

Contact, and all proctors for the Entity. Use additional sheets if necessary.

“I affirm that the information contained in this document is true and correct. I affirm

that any “misrepresentations” of this Requirement is grounds for revocation, and non-

renewal of Authorization for Certification from the Colorado Dept. of Transportation.”

 Signature:

Signed this day of:

Witness: Date:

 Signature:

Signed this day of:

Witness: Date:

 Signature:

Signed this day of:

Witness: Date:

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PART IV: 1

ST

TIME FLAGGER SURVEY-CERTIFICATION ONLY

Participant Name: Date:

Location: Proctor/Entity:

Your thoughtful feedback regarding this class is

requested. By filling out this form, you are helping to

evaluate the training that is offered to you. Use page thirteen

(13) to add your own comments. Supply any information

that you feel is important for the Co. Dept. Of

Transportation to know.

Disagree

Somewhat

Agree

Completely

Agree

Course Content

1. The learning objectives were made apparent?

2. The material supported the learning objective?

3. The course enhanced my knowledge of the subject

matter?

4. The course enhanced my ability to perform the job

functions?

Effectiveness

1. During class, I had an opportunity to practice the

skills I learned with a Stop/Slow paddle?

2. I will be able to use these skills in the future?

3. I received feedback from the proctor?

4. Did the proctor answer all my questions

5. Would you use this entity again?

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PART IV: 1

ST

TIME FLAGGER SURVEY-CERTIFICATION ONLY

Your thoughtful feedback regarding this class is

requested. By filling out this form, you are helping to

evaluate the training that is offered to you. Use page thirteen

(13) to add your own comments. Supply any information

that you feel is important for the Co. Dept. Of

Transportation to know.

Disagree

Somewhat

Agree

Completely

Agree

Proctor Evaluation: The proctor

1. Studied the manual with me before testing?

2. Knew the material well and kept me engaged

throughout the class.

3. Encouraged participation and discussion?

4. Allowed adequate time for questions?

5. Issued a Flagger Certification Card.

6. Offered Employment; temporary or permanent?

 What were the objectives of the Flagger Certification Class?

 What materials were used by the proctor?

 How long did the class last?

_____________________________________________________________________________________

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PART V: RETURNING FLAGGER SURVEY- RECERTIFIATION

ONLY

Participant Name: Date:

Location: Entity:

1. How long have you been a flagger?

2. How long have you been employed by the entity?

3. Were you a flagger previous to becoming employed with the entity?

4. Are you a temporary employee/contracted/or permanent?

5. When does your current Flagger or TCS card expire?

6. Do you plan on renewing your certification?

7. Do you plan to stay employed with the entity?

8. What projects have you flagged in the last year?

9. Do you want to flag more projects?

10. Are you interested in becoming a Traffic Control Supervisor, or learning more about flagging?

11. Did you have a problem flagging or other complications while on a project?

12. Were accommodations made for you, if necessary?

Please give details of one (1) project that you have flagged, and any additional

information that you feel is important for the Colorado Department of Transportation to

know.

_____________________________________________________________________________________

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__________________________________________________________________________________

Thank you for your cooperation!!

CDOT will retain the original Quality Assurance documentation and will send comments

and/or recommendations to the Entity, via email, after reviewing the material.

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