Fillable Massachusetts Department of Transport Qualified Traffic Control Equipment Submission Form for Vehicle and Pedestrian Signal Modules

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Massachusetts Department of Transport Qualified Traffic Control Equipment Submission Form for Vehicle and Pedestrian Signal Modules

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Qualified Traffic Control Equipment Submission Form for
Vehicle and Pedestrian Signal Modules
Submission Instructions: Please submit one application per product. Catalogue cuts shall be included as
attachments. Test results from an independent test lab shall be submitted to ensure compliance. All other
testing results or certifications which may assist in evaluation may also 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, and the Institute of Transportation Engineers LED performance
specifications. 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
Product Type
Veh
icle Module Pedestrian Module
Other:
Part C. Technical Product Information
Please complete this section for vehicle modules, only.
Module Dimensions
Module Type
Circular Arrow
Bicycle Transit
Other:
Module Color
Green Yellow Red
Other:
Incandescent Look Yes No
Programmable Visibility
Yes No
Please complete this section for pedestrian signal modules, only.
M
odule Dimensions
Countdown Indication Included Separate Module
Application Revision: November 13, 2014 Signal Modules Application
Qualified Traffic Control Equipment: http://goo.gl/OS7o5N Page 1 of 3
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 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 13, 2014 Signal Modules 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
C
ontact Title
Company
Website
Address City, State ZIP
Email Phone
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 13, 2014 Signal Modules 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 and Pedestrian Signal Modules

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Completed 13 May 2020

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