Fillable Massachusetts Department of Transport Qualified Traffic Control Equipment Submission Form for Vehicle Detection Systems

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Massachusetts Department of Transport Qualified Traffic Control Equipment Submission Form for Vehicle Detection Systems

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Qualified Traffic Control Equipment Submission Form for
Vehicle Detection Systems
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
Company
A
ddress
City, State ZIP
Phone
Email
Part B. Basic Product Information
Name or Model #
Description
Link to product cutsheet
Part C. Technical Product Information
Detection System Type
Wire Loop V
ideo Radar
Other:
Please
complete this section for passive detection systems, only.
Product Type
Sens
or Processor
Other:
Detection Zone Area Sto
p Line Advanced
Detection Zone Range
Detection Zone Setup
Ne
eds/Procedures
Application Revision: October 31, 2014 Vehicle Detection Application
Qualified Traffic Control Equipment: http://goo.gl/OS7o5N Page 1 of 3
Please complete this section for detection processors and interface cards.
Mount Type
Rack Shelf
Other:
Channels per Unit
Failure/Fault Monitoring
Yes (explain):
No
Counting Capability
Yes (explai
n):
No
Classification Capability
Yes (explain):
No
Additional Technical Notes (if necessary):
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 product currently in use in Massachusetts?
Yes No
If Ye
s, 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 No
If Yes, please explain:
Recommended Routine Maintenance Program (if applicable):
W
arranty Information:
Application Revision: October 31, 2014 Vehicle Detection 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
Con
tact Title
Company
Website
Address City, State ZIP
Email Phone
Reference #1
Co
ntact 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: October 31, 2014 Vehicle Detection 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 Vehicle Detection Systems

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Completed 8 May 2020

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