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

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

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Qualified Traffic Control Equipment Submission Form for
Traffic Signal Controllers
Submission Instructions: Please submit one application per product. Catalogue cuts shall be included as
attachments. NEMA test results from an independent test lab shall be submitted to ensure compliance. Other
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
Compa
ny
Address
City, State ZIP
Phone
Email
Part B. Basic Product Information
Name o
r Model #
Description
Link to product cutsheet
Part C. Technical Product Information
Controller Specifications NEMA TS2 Type 1
NEMA TS2 Type 2 ATC
(version):
Controller Functionality Mas
ter Controller Secondary Controller
Does this product provide a Remote Communication Interface? Yes N
o
If Yes, please describe:
Additional Technical Notes (if necessary):
Application Revision: October 24, 2014 Traffic Signal Controller Application
Qualified Traffic Control Equipment: http://goo.gl/OS7o5N Page 1 of 3
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 th
is 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 N
o, please explain:
Have there been any recalls on this product? Yes N
o
If Yes, please explain:
Describe Software/ Firmware Upgrade Procedure(s):
Recommended Routine Maintenance Program (if applicable):
Warranty Information:
Application Revision: October 24, 2014 Traffic Signal Controller 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
C
ompany
Website
Address City, State ZIP
Email Ph
one
Reference #1
Contact Title
Agency
Email P
hone
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: October 24, 2014 Traffic Signal Controller 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 Traffic Signal Controllers

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Completed 13 May 2020

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