Fillable Massachusetts Department of Transport Qualified Traffic Control Equipment Submission Form for Signal Preemption Devices

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Massachusetts Department of Transport Qualified Traffic Control Equipment Submission Form for Signal Preemption Devices

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Qualified Traffic Control Equipment Submission Form for
Signal Preemption Devices
Submission Instructions: Please submit one application per product. Catalogue cuts shall be included as
attachments. Testing results or certifications which may assist in evaluation may be included. All equipment
shall comply with the latest editions of Section 815 - Traffic Control Signals of the Standard Specifications,
including Supplemental and Interim editions, NEMA, the Massachusetts Electrical Code, and applicable
Underwriters Laboratories standards. 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
Name or Model #
Description
Link to product cutsheet
Part C. Technical Product Information
Product Function
Emitter Phase Selector
Receiver Confirmation Light
Other:
Will this product function only with other proprietary preemption equipment? Yes No
Explanation (if needed):
Please complete this section for Receivers, only.
Detectors per Unit
Channels per Unit
Transmission Method
Infrared GPS
Other:
Please complete this section for Phase Selectors, only.
Number of Channels
Mount Type
Rack Shelf
Other:
Priority Settings
Yes (explain):
No
Activation Log
Yes (explain):
No
Application Revision: November 5, 2014 Signal Preemption Devices Application
Qualified Traffic Control Equipment: http://goo.gl/OS7o5N Page 1 of 3
Additional Technical Notes (if necessary):
Part D. Product Use
Has this product, or one similar, been previously submitted to MassDOT? Yes No
I
f 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:
Application Revision: November 5, 2014 Signal Preemption Devices Application
Qualified Traffic Control Equipment: http://goo.gl/OS7o5N Page 2 of 3
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 P
hone
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 5, 2014 Signal Preemption Devices 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 Signal Preemption Devices

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Completed 13 May 2020

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