Fillable Massachusetts Department of Transport Qualified Traffic Control Equipment Submission Form for Barrier End Treatments and Impact Attenuators

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Massachusetts Department of Transport Qualified Traffic Control Equipment Submission Form for Barrier End Treatments and Impact Attenuators

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Application Revision: October 23, 2014
Qualified Traffic Control Equipment:
http://goo.gl/OS7o5N
End Treatments and Attenuators Application
Page 1 of 4
Qualified Traffic Control Equipment Submission Form for
Barrier End Treatments and Impact Attenuators
Submission Instructions: Please submit one application per product. Catalogue cuts shall be included as
attachments. All FHWA Federal-aid eligibility letters 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
editions of Section 601 - Highway Guard, Section 628 - Permanent Impact Attenuators, and/or Section 850 -
Traffic Controls for Construction and Maintenance Operations of the Standard Specifications
, including
Supplemental and Interim editions. Per Engineering Directive E-95-008, end terminal applications must include
design drawings that are stamped and signed by a Professional Engineer registered in Massachusetts. Upon
evaluation MassDOT Highway Division will contact you.
Part A. Applicant Information
Today's Date
Name
Company
Address
City, State ZIP
Phone
Email
M
assachusetts P.E. Stamp and Signature:
Date:
Part B. Basic Product Information
Name o
r Model #
Description
Link to product cutsheet
Product Type
Cable Barrier Terminal Guardrail Terminal Crash Cushion
Truck Mounted Attenuator Other:
Application Revision: October 23, 2014
Qualified Traffic Control Equipment:
http://goo.gl/OS7o5N
End Treatments and Attenuators Application
Page 2 of 4
Part C. Technical Product Information
Test Level n/a TL-2 TL-3 TL-4 TL-5
Methodology NCHRP 350 MASH
FHWA Acceptance Letter(s):
FHWA Limits on Use
Designed for the following
impact types
Point Protection Med
ian (Opposite Side/Opposite Dir
ection)
Shoulder (One-sided) Gore (Two-sided)
System designed for
attachment to
Single Face Guardrail Rail Element Type(s):
Double Face Guardrail Rail Elem
ent Type(s):
Shoulder Concrete Barrier
Median Concrete Barrie
r
Free Standing (does not attach to other hardware)
Is
this product capable of redirection? Yes No
Is this product gating? Yes No
If product is both capable
of redirection and gating,
please explain
Please
complete this section for Guardrail Terminals, only.
Energy Dissipation Energy Absorbing N
on-Energy Absorbing
Terminal Design Flared Tangent
Is this p
roduct cert
ified for 31-in. height guardrail systems? Yes No
Please complete this section for Crash Cushions, only.
Cushion Type
Low-Maintenance and
/or Self-Restoring*
Sacrificial
Other:
*The category ty
pe of “Low Maintenance and/or Self Restoring” includes those crash cushions
that either suffer
very little, if any, damage upon impact and are easily pulled back into their
full operating condition, or they partially rebound after an impact and may only need an
inspection to ensure that no parts have been damaged, misaligned, etc.
Intended Use
Permanent Temporary/Work Zone
Length:
Width: Height:
Please co
mplete this section for Truck Mounted Attenuators, only.
Is the TMA, or its components, reusable after a designed impact? Yes No
If Yes, please explain
Application Revision: October 23, 2014
Qualified Traffic Control Equipment:
http://goo.gl/OS7o5N
End Treatments and Attenuators Application
Page 3 of 4
Part D. Product Use
Has 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 produc
t currently in use in Massachusetts? Yes No
If Yes, please explain:
State DOTs that have
a
pproved 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:
Application Revision: October 23, 2014
Qualified Traffic Control Equipment:
http://goo.gl/OS7o5N
End Treatments and Attenuators Application
Page 4 of 4
Part E. Contact Information
Supplier/
Distributer
Contact Title
Company
Website
Address City, State ZIP
Email Phone
Manufacturer
Contact Title
Com
pany
Website
Address City
, State ZIP
Email Phone
Referen
ce #1
Contact Title
Agency
E
mail Phone
R
eference #2
Cont
act Title
Agen
cy
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
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Massachusetts Department of Transport Qualified Traffic Control Equipment Submission Form for Barrier End Treatments and Impact Attenuators

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Completed 13 May 2020

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