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

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

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Qualified Traffic Control Equipment Submission Form for
Temporary Barrier
Submission Instructions: Please submit one application per product. If barrier system comes with both
Restrained and Non-Restrained options, please submit a separate application for each. Catalogue cuts shall be
included as attachments. Other testing results or certifications, such as NTPEP data or FHWA letters, which may
assist in product evaluation may be included.All equipment shall comply with the latest edition of Section 629 -
Concrete Barrier and/or 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
Compa
ny
Address
City, State ZIP
Phone
Email
Part B. Basic Product Information
Name or Model #
Description
Link to product cutsheet
Product Type
Rest
rained Barrier
Non-Restrined Barrier
Part C. Technical Product Information
Test Lev
el n/a TL-2 TL-3 TL-4 TL-5
Methodology NCHRP 350 Manual for Assessing Safety Hardware
FHWA Acceptance Letter(s):
FH
WA Limits on Use
Product Material(s)
Product Characteristics
Unit Width: Unit Height:
Unit Length: Unit Weight:
Single-Sided Double Sided
Application Revision: November 3, 2014 Temporary Barrier Application
Qualified Traffic Control Equipment: http://goo.gl/OS7o5N Page 1 of 3
Describe Joint Connection
System
Dynamic Deflection Under Test Designation 3-11:
Length of Need for Anchorage
1
:
1
Length of need for anchorage is defined as the minimum additional length of barrier needed upstream and downstream
of the hazard or work zone being protected.
Additional Technical Notes (if necessary):
Part D. Product Use
Has this product, or one similar, been previously submitted to MassDOT? Yes No
If Ye
s, please explain:
Is this a replacement product for one currently approved by MassDOT? Yes No
If Y
es, please explain:
Is this product currently in use in Massachusetts? Yes No
I
f Yes, please explain:
State DOTs that have
approved this product:
Is this product in commercial production? Yes No
If Yes, for how long?
I
f No, please explain:
Have there been any recalls on this product? Yes No
If Yes, please explain:
Warranty Information:
Application Revision: November 3, 2014 Temporary Barrier 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
Co
mpany
Website
Address City, State ZIP
Email Phone
Reference #1
Contact Title
A
gency
Email Phone
Reference #2
Co
ntact 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 3, 2014 Temporary Barrier 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 Temporary Barrier

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Completed 13 May 2020

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