FDOT Design Manual

Topic #625-000-002

FDOT Design Manual

103 – Standard Forms

103 Standard Forms

103.1 General

This chapter contains fillable portable document format (PDF) of the standard forms found

in the FDOT Design Manual (FDM). The form number assigned to each form corresponds

to the FDM chapter in which it is discussed. Refer to the related chapter for instruction

on the use of each form.

January 1, 2024

Form 110

STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION

Proprietary Product Certification

To: Date:

District or Turnpike Design Engineer

Financial Project ID:

Federal Aid Number:

Project Name:

State Road Number: Co. / Sec. / Sub.:

Begin Project MP: End Project MP:

Attach justification and supporting documents.

Mark the appropriate certification (below):

“I, , , of the ,

Print Name of Initiator Position Title Name of Agency

do hereby certify that the following condition(s) apply. Mark appropriately:

☐ that this patented or proprietary item is most compatible with existing highway facilities;

☐ that this patented or proprietary item provides greater flexibility with existing and/or future

highway facilities;

☐ that this patented or proprietary item fosters innovation in highway transportation technology;

☐ that this patented or proprietary item satisfies Build America/Buy America (BABA) requirements;

☐ that this patented or proprietary item is included as FDOT Approved Products Listing (APL)

Number ___________;

☐ that no equally suitable alternative exists for this patented or proprietary item.”

Signature Date

Form 110

For Department Use Only

“I, , ,

Print Name, District/Turnpike Design Engineer Signature

of the Florida Department of Transportation, do hereby approve this certification request made in

accordance with the policies and procedures of the Department. Mark appropriately:

☐ that this patented or proprietary item is most compatible with existing highway facilities;

☐ that this patented or proprietary item provides greater flexibility with existing and/or future highway facilities;

☐ that this patented or proprietary item fosters innovation in highway transportation technology;

☐ that this patented or proprietary item satisfies Build America / Buy America (BABA) requirements;

☐ that this patented or proprietary item is included as FDOT Approved Products Listing (APL) Number ___________;

☐ that no equally suitable alternative exists for this patented or proprietary item.”

Identify any conditions and limitatio

ns:

Signature Date

Form 121-A

Bridge Development Report Submittal Checklist

Project Name

Financial Project ID

FA No. Projects of Division Interest Yes No

NHS Yes No

Date FDOT Project Manager

ITEMS STATUS

(b)

(1) Typical Sections for Roadway and Bridge

(a)

….………….

(2) Roadway Plans in Vicinity of Bridge

(a)

….………………...

(3) Maintenance of Traffic Requirements

(a)

….…………….…

(4) Bridge Hydraulics Report

(c)

….……………………………..

(5) Geotechnical Report

(c)

….…………………………………..

(6) Bridge Corrosion Environmental Report

(c)

….…………….

(7) GRS Abutments Feasibility Assessment

(d)

….……………

(8) Precast Feasibility Assessment…………………………...

(9) Existing Bridge Plans……………………………………….

(10) Existing Bridge Inspection Report…………………………

(11) Existing Bridge Load Rating………………………….…….

(12) Wildlife Connectivity………………………………………..

(13) Utility Requirements………………………………………..

(14) Railroad Requirements…………………………………….

(15) Retaining Wall and Bulkhead Requirements……………..

(16) Lighting Requirements……………………………………..

(17) ADA Access Requirements………………………………..

(18) Other………………………………………………………….

(a) Must be approved by District before BDR submittal.

(b) Select appropriate status: Provided, Not Applicable, Comments Attached

(d) GRS = Geosynthetic Reinforced Soil

Select Status

Form 121-B

Standard Peer Review Certification Letter

Florida Department of Transportation

District

Attn:

Reference: Independent Peer Review Category 2 Structures

Financial Project ID:

Federal Aid Number:

Contract Number:

Submittal:

90% Bridge Plans

Submittal

Bridge Number(s):

Dear ,

Pursuant t

o the requirements of the Contract Documents,

hereby certifies that an independent peer review of the above-referenced submittal has been

conducted in accordance with FDM 121 and all other governing regulations. Component plans

that were included in the peer review are as follows:

Outstanding / Unresolved Comments and Issues:

Form 121-B

Certification Statement:

I certify that the component plans listed in this letter have been verified by independent review

and are in compliance with all requirements presented in the Contract Documents. Independent

Peer Review comments and comment resolutions have been included in this submittal under

separate cover.

I have also at

tached a current copy of the Firm's Independent Peer Review Prequalification Letter

issued by the Department with the “Approved Rates” Section redacted.

Please do not hes

itate to contact me if you have any questions.

Name of Independent Peer Review Firm

Name of Independent Peer Reviewer

Title

Signature

Florida Professional Engineer Lic. No.

Form 121-C

Certification Letter

Florida Department of Transportation

District

Attn:

Reference: Independent Peer Review Category 2 Structures

Financial Project ID:

Federal Aid Number:

Contract Number:

Submittal: Final Bridge Plans

Submittal

Bridge Number(s):

Dear ,

Pursuant to the requirements of the Contract Documents,

hereby certifies that an independent peer review of the above-referenced submittal has been

conducted in accordance with FDM 121 and all other governing regulations. Component plans

that were included in the peer review are as follows:

Certification Statement:

I certify that the component plans listed in this letter have been verified by independent review,

that all review comments have been adequately resolved, and that the plans are in compliance

with all Department and FHWA requirements presented in the Contract Documents.

I have been provided with all 90% Department or Department Representative Electronic Review

Comments (ERC). I certify that I have reviewed the comments and have considered these

concerns in the Independent Peer Review. See attached 90% ERC comments.

I have also a

ttached a current copy of the Firm's Independent Peer Review Prequalification Letter

issued by the Department with the “Approval Rates” section redacted.

Form 121-C

Please do not hesitate to contact me if you have any questions.

Name of Independent Peer Review Firm

Name of Independent Peer Reviewer

Title

Florida Professional Engineer Lic. No.

Name of IPR Quality Assurance Manager

Title

Florida Professional Engineer Lic. No.

[Insert Signature,

Date and Seal

here.]

[Insert Signature,

Date and Seal

here.]

Form 121-D

Independent Department Review Certification Letter

Florida Department of Transportation

District

Attn:

Reference: Independent Department Review Category 2 Structures

Financial Project ID:

Federal Aid Number:

Contract Number:

Submittal:

90% Bridge Plans

Submittal

Bridge Number(s):

Dear ,

Pursuant to

the requirements of the Contract Documents,

hereby certifies that an Independent Department Review of the above-referenced submittal has

been conducted in accordance with FDM 121 and all other governing regulations. Component

plans that were included in the Independent Department Review are as follows:

Outstanding / Unresolved Comments and Issues:

Form 121-D

Certification Statement:

I certify that the component plans listed in this letter have been verified by independent review

and are in compliance with all requirements presented in the Contract Documents. Independent

Department Review comments and comment resolutions have been included in this submittal

under separate cover.

Please do not hesi

tate to contact me if you have any questions.

Name of Independent Department Review Firm

Name of Independent Department Reviewer

Title

Signature

Florida Professional Engineer Lic. No.

Form 121-E

Independent Department Review Certification Letter

Florida Department of Transportation

District

Attn:

Reference: Independent Department Review Category 2 Structures

Financial Project ID:

Federal Aid Number:

Contract Number:

Submittal: Final Bridge Plans

Submittal

Bridge Number(s):

Dear ,

Pursuant to the requirements of the Contract Documents,

hereby certifies that an Independent Department Review of the above-referenced submittal

has been

conducted in accordance with FDM 121 and all other governing regulations.

Component plans that were included in the Independent Department Review are as follows:

Certification Statement:

I certify that the component plans listed in this letter have been verified by independent review,

that all review comments have been adequately resolved, and that the plans are in compliance

with all Department and FHWA requirements presented in the Contract Documents.

I have been provided with all 90% Department or Department Representative Electronic Review

Comments (ERC). I certify that I have reviewed the comments and have considered these

concerns in the Independent Department Review. See attached 90% ERC comments.

Form 121-E

Please do not hesitate to contact me if you have any questions.

Name of Independent Department Review Firm

Name of Independent Department Reviewer

Title

Florida Professional Engineer Lic. No.

Name of IPR Quality Assurance Manager

Title

Florida Professional Engineer Lic. No.

[Insert Signature,

Date and Seal

here.]

[Insert Signature,

Date and Seal

here.]

Form 122-A

Submittal/Approval Letter

To: Date:

District or Turnpike Design Engineer

Financial Project ID:

Federal Aid Number:

New Const. RRR Other __________________

Project Name:

State Road Number:

Begin Project MP:

Co./Sec./Sub.

End Project MP:

FHWA Project of Division Interest:

Yes No

Request for: Design Exception Design Variation Design Variation Memorandum

Community Aesthetic Feature: Conceptual Final

Re-submittal: Yes No Original Ref# ______ - ______ - ______

Requested for the following element(s):

Design Speed Lane Width

Design Loading Structural Capacity Vertical Clearance

Superelevation Horizontal Curve Radius

Shoulder Width Cross Slope

Maximum Grade Stopping Sight Distance

Other

Recommended by:

Date

Name:

Responsible Professional Engineer or Landscape Architect (Landscape-Only Projects)

Approvals:

Date

Name:

District or Turnpike Design Engineer

Date

Name:

District Structures Design Engineer

Date

Name:

State Roadway Design Engineer

Date

Name:

State Structures Design Engineer

Date

Name:

Chief Engineer

Date

Name:

FHWA Division Administrator

Form 122-B

Project Design Variation Memorandum Form 122-B

To: Date:

District or Turnpike Design Engineer

Financial Project ID:

_________________ New Const. Other ______________

Design Speed: _______ Posted Speed: ________

Context Classification: _______

Federal Aid Number: _________________

Project Name: _________________________________________________

State Road Number: _________________ Co./Sec./Sub. ________________

Begin Project MP: _________________ End Project MP: ________________

Other Project Information: ________________________________________

Request for:

Design Variation

For District Use Only

Design Element MP: B

eg-End Existing Proposed Requir

ed Attr. Crashes Approved Denied Addl. Docum.

1. ______________ ___________ _______ _______ _______ ☐ ☐ ☐ ☐

Justification:

___________________________________________

__________________________________________________________

2. ______________ ___________ _______ _______ _______ ☐ ☐ ☐ ☐

Justification:

___________________________________________

__________________________________________________________

3. ______________ ___________ _______ _______ _______ ☐ ☐ ☐ ☐

Justification:

___________________________________________

__________________________________________________________

4. ______________ ___________ _______ _______ _______ ☐ ☐ ☐ ☐

Justification:

___________________________________________

__________________________________________________________

RRR

Form 122-B

Request for: Design Variation (Con’t)

For District Use Only

Design Element

MP: Beg-End Existing Proposed Re

quired Attr. Crashes Approved Denied Addl. Docum.

5. ______________ ___________ _______ _______ _______ ☐ ☐ ☐ ☐

Justification:

_____________________________________________________________________________________________________

6. ______________ ___________ _______ _______ _______ ☐ ☐ ☐ ☐

Justification:

_____________________________________________________________________________________________________

Appendices: Yes No

If yes, list appendices in order: ________________________________________________________________________________

_________________________________________________________________________________________________________

Recommended by:

__________________________________ Date _____________

Name:

Responsible Professional Engineer or Landscape Architect (Landscape-Only Projects) (Seal)

Approvals:

________________________________

___Date ____________ ___________________________________Date ____________

Name: Name:

District or Turnpike Traffic Operations Engineer District or Turnpike Design Engineer

Form 126-A

Initial Meeting And Methodology Checklist

The Applicant should prepare the following list of items to discuss at the initial meeting. The District Review

Team may require the Applicant to address these items in the Concept Report.

Project Information

☐Project Location, Limits, and Length

☐Project Purpose

☐Conceptual plan (including transitions to and

from the lane repurposing section)

☐Existing and long-range future AADT

☐Environmental and utilities impacts

☐Consistency of the proposed project with the

applicable Long-Range Transportation Plan

(LRTP), Transportation Improvement Program

(TIP), Transit Development Plan (TDP),

comprehensive plan, master plans, visions, and

Complete Streets initiatives

☐Status of the roadway as an Evacuation Route,

and freight route

☐

☐S

tatus of the roadway as a major transit corridor

per the LRTP or TDP

☐Proposed use(s) for the right-of-way after lanes

are eliminated (e.g., widened sidewalks, bicycle

lanes, landscaping, on-street parking, transit lanes)

☐Impact on bicycle/pedestrian infrastructure and

connectivity

☐Impact on parking

☐Impact on transit routes, stop locations (including

appropriateness of turn radii and lane widths),

include total number of stops and routes in the area.

☐Existing right-of-way width and any proposed

changes to the right-of-way width

☐Anticipated changes in jurisdictional

responsibility for ownership or maintenance of the

roadway

☐Existing and anticipated changes in functional

classification

☐Existing and anticipated changes to access

management classification

☐Jurisdiction(s) in which the Project is Located

☐Proposed Change in Lane Configuration

☐Project Schedule

☐Existing and anticipated context classification

☐Public Involvement, agency outreach and

endorsement

☐Existing design and posted speeds

☐Existing and future typical section

☐Target speed with anticipated changes in posted

speed limits and design speeds

☐Need for design variations or design exceptions

☐Plan for obtaining input and review from businesses,

residents, and other stakeholders

☐Plan for receiving endorsement from elected officials

☐Funding source and cost estimates

☐Size of impact area-parallel and cross streets

☐Potential implementation strategy and partner

commitments

☐Impact on School crossing locations and midblock

crossing

☐Need to add, remove, or modify traffic signals

☐Existing or proposed roundabouts

☐Near and long-range multimodal level of service

(LOS,) network traffic analysis, and queuing analysis

for intersections and segments in the impact area

under build and no-build scenario

☐If the project is transit related, transit analysis

including increased ridership

☐Quantitative Safety Analysis☐Mitigation to address

the significant adverse impact on state roads and

regional transportation system

☐Crash data summary and analysis for the segments

and intersections within the project limits

☐Case-specific special considerations to be

determined (e.g., railroad crossing improvements)

Form 126-B

Lane Repurposing Initial Notice To Central Office

To: From: Date:

Systems Management Administrator District Lane Repurposing Coordinator

The intent of this notice is to inform Central Office that District has received

a request for lane repurposing on the State Highway System.

PROJECT INFORMATION

State Road and Project Location:

Roadway ID:

_____________________ Project Limits (MP): from ___________ to

Roadway ID:

_____________________ Project Limits (MP): from ___________ to

Context Classification: Access Management Classification:

Applicant:

Project Description:

____________________________________________________________________________________

Proposed Change in Cross Section: From lanes to lanes

☐ SIS ☐ NHS

ACTIONS AND OUTCOMES TO DATE

District staff participated in a meeting with

on to formally commence the lane repurposing review process. At that

meeting, District staff provided an overview of the lane repurposing review process and the

Applicant shared initial information about the lane repurposing project. The District determined

the specific review process and analysis methodology for the lane repurposing request,

including a network-level traffic analysis per the FDOT Traffic Analysis Handbook.

NEXT STEPS

The Applicant will submit a Draft Concept Report (containing a proposed typical section) as the

lane repurposing review process proceeds. If the District reviewers find the Draft Concept Report

acceptable, the Applicant submits a formal Application Package (including the Final Concept

Report) to the District. If the Application Package is complete and acceptable, the lane

repurposing request will be approved at the District level. The Final Application Package along

with signed Form-C will be sent to Central Office for final approval.

Concurrences:

District Planning and Environmental Administrator

Date:

District Design Engineer

Date:

District Traffic Operations Engineer

Date:

Form 126-C

Lane Repurposing Final Review And Approval Notice To Central Office

The intent of this notice is to inform Central Office that District has

completed the review for the following lane repurposing project on the State Highway System.

OJECT INFORMATION

State Road and Project Location:

Roadway ID: _____________

Project Limits (MP): From ______________to

Roadway ID: _____________

Project Limits (MP): From ______________to

Context Classification: ____________ Access Management Classification: ________________

Existing Posted Speed: __________ Proposed Posted Speed: __________

Design Speed: __________ Target Speed: ____________

Transit facilities (stops and routes):  Yes  No

Applicant:

Project Description:

____________________________________________________________________________________

Proposed Change in Cross Section: From lanes to lanes

☐ SIS ☐ NHS

Attachments:  Concept Report  Plan views  Typical sections  Traffic Analyses

strict Concurrences:

District Planning and Environmental Administrator

Date:

District Design Engineer

Date:

District Traffic Operations Engineer

Central Office Concurrence:

Date:

Chief Planner

Final Approval:

Date:

Chief Engineer

Date:

Form 126-D

Lane Repurposing Withdrawal Notice To Central Office

The intent of this notice is to inform Central Office that District has

withdrawn the following lane repurposing project on the State Highway System.

OJECT INFORMATION

State Road and Project Location:

Roadway ID: _____________

Project Limits (MP): From ______________to

Roadway ID: _____________

Project Limits (MP): From ______________to

Context Classification: ____________ Access Management Classification: ________________

Existing Posted Speed: __________ Proposed Posted Speed: __________

Design Speed: __________ Target Speed: ____________

Transit facilities (stops and routes):  Yes  No

Applicant:

Reason for Withdrawal of Project:

____________________________________________________________________________________

Proposed Change in Cross Section: From lanes to lanes

☐ SIS ☐ NHS

Attachments:  Concept Report  Plan views  Typical sections

strict Concurrences:

District Planning and Environmental Administrator

Date:

District Design Engineer

Date:

District Traffic Operations Engineer

Central Office Concurrence:

Date:

Chief Planner

Final Approval:

Date:

Chief Engineer

Date:

Form 128-A

Design Plans Phase Review

DATE:

TO:

FROM: COPIES:

SUBJECT: Response to Phase Review

REF: Financial Project ID

FA Project Number

County

APPROVED: CONCURRENCE:

Responsible Professional Eng. * District Design Engineer

(Name of Consultant Firm) * District Structures Design Engineer

* District Project Management Engineer

* As appropriate

Form 128-B

Design Plans Component Review

DATE:

TO:

FROM: COPIES:

SUBJECT: Response to Component Review

REF: Financial Project ID

FA Project Number

County

APPROVED: CONCURRENCE:

Responsible Professional Eng. * District Design Engineer

(Name of Consultant Firm) * District Structures Design Engineer

* District Project Management Engineer

* As appropriate

Form 128-C

Special Provisions

DATE:

TO:

FROM: COPIES:

SUBJECT: Response to Component Review

REF: Financial Project ID

FA Project Number

County

APPROVED: CONCURRENCE:

Responsible Professional Eng. * District Design Engineer

(Name of Consultant Firm) * District Structures Design Engineer

* District Project Management Engineer

* As appropriate

Form 130-A

18 KIP Equivalent Single Axle Loads (ESAL)

Financial Project ID

State Road No.

County

I have reviewed the 18 KIP Equivalent Single Axle Loads to be used for pavement design

on this project. I hereby attest that these have been developed in accordance with the

FDOT Project Traffic Forecasting Procedure using historical traffic data and other

available information.

Name

Signature

Title

Organizational Unit

Date

Form 130-B

Project Traffic

Financial Project ID

State Road No.

County

I have reviewed the Project Traffic to be used for design on this project. I hereby attest

that it has been developed in accordance with the FDOT Project Traffic Forecasting

Procedure using historical traffic data and other available information.

Name

Signature

Title

Organizational Unit

Date

Form 131

Form 131 Agency Maintenance Agreement

Sample Local Agency Maintenance Agreement

For Work Performed by the Department

Sheet 1 of 3

Financial Project ID:

Federal Aid No.

Local Agency:

Project Description:

Bridge No.:

MAINTENANCE AGREEMENT

THIS AGREEMENT, made and entered into on this day of ,

20 , by and between the STATE OF FLORIDA DEPARTMENT OF

TRANSPORTATION (hereinafter called “DEPARTMENT”), and

, Florida (hereinafter called “LOCAL AGENCY”);

WITNESSETH:

WHEREAS, the DEPARTMENT is preparing to undertake a project within the LOCAL

AGENCY and LOCAL AGENCY identified and known to the parties by Financial Project

I.D. which will be of benefit to the LOCAL AGENCY; and

WHEREAS, approval of federal aid necessary to the project requires agreement by

the LOCAL AGENCY to maintain the project;

NOW, THEREFORE, in consideration of the premises, the parties hereby agree as

follows:

1. The DEPARTMENT will undertake the project and obtain approval of the Federal

Highway Administration for federal participation.

2. Upon completion and acceptance, the LOCAL AGENCY will assume responsibility

for maintenance of the project and will conduct such maintenance in accordance with

approved state standards.

3. To the extent permitted by law, LOCAL AGENCY must indemnify, defend, and hold

harmless the DEPARTMENT and all of its officers, agents, and employees from any

claim, loss, damage, cost, charge, or expense arising out of any act, error, omission

or negligent act by LOCAL AGENCY, its agents, or employees, during the

performance of the Agreement, except that neither LOCAL AGENCY, its agents, or

its employees will be liable under this paragraph for any claim, loss, damage, cost,

charge, or expense arising out of any act, error, omission, or negligent act by the

DEPARTMENT or any of its officers, agents, or employees during the performance

of the Agreement. Nothing herein must waive the rights of sovereign immunity of

either party.

Form 131

Form 131 Agency Maintenance Agreement

Sample Local Agency Maintenance Agreement

For Work Performed by the Department

Sheet 2 of 3

4. In the event there are cost overruns, supplemental agreements (specifically incurred

in the areas located off the State Highway System), and or liquidated damages not

eligible to be paid for by federal funds due to the Federal Highway Administration

determining that said costs are non-participating costs, the LOCAL AGENCY must

be responsible for one hundred percent (100%) of the funds required to make up the

shortfall not paid by federal funds. The Project is off of the “State Highway System,”

therefore, in accordance with Section 339.08(1), Florida Statutes, State funding

cannot be used for payments of non- participating costs on this Project. (Examples

of non-participating items could be fishing piers; premium costs due to design or CEI

errors or omissions; material or equipment called in for the plans but not used in the

construction, as referenced in the Federal Aid Policy Guide 23, CFR Section

635.120).

a. Should such shortfalls occur, due to a determination that said costs are

non-participating, the LOCAL AGENCY agrees to provide, without delay, a

deposit within fourteen (14) calendar days of notification from the

Department, to ensure that cash on deposit with the Department is

sufficient to fully fund the shortfall. The Department must notify the LOCAL

AGENCY as soon as it becomes apparent there is a shortfall; however,

failure of the Department to so notify the LOCAL AGENCY must not relieve

the LOCAL AGENCY its obligation to pay for its full participation of non-

participating costs during the Project and on final accounting, as provided

herein below. If the LOCAL AGENCY cannot provide the deposit within

fourteen (14) days, a letter must be submitted to and approved by the

Department’s project manager indicating when the deposit will be made.

The LOCAL AGENCY understands the request and approval of the

additional time could delay the project, and additional non-participating

costs may be incurred due to the delay of the project.

5. The DEPARTMENT intends to have its final and complete accounting of all costs

incurred in connection with the work performed hereunder within three hundred sixty

days (360) of final payment to the Contractor. The Department considers the Project

complete when the final payment has been made to the Contractor, not when the

construction work is complete. All non-participating Project cost records and

accounts must be subject to audit by a representative of the LOCAL AGENCY for a

period of three (3) years after final close out of the Project. The LOCAL AGENCY

will be notified of the final non-participating cost of the project. Both parties agree

that in the event the final accounting of total non-participating costs pursuant to the

terms of this Agreement is less than the total deposits to date, a refund of the excess

Form 131

Form 131 Agency Maintenance Agreement

will be made by the Department to the LOCAL AGENCY. If the final accounting is not

performed within three hundred and sixty (360) days, the LOCAL AGENCY is not relieved

from its obligation to pay.

6. In the event the final accounting of total non-participating costs are greater than the

total deposits to date, the LOCAL AGENCY will pay the additional amount within

forty (40) calendar days from the date of the invoice from the Department. The

LOCAL AGENCY agrees to pay interest at a rate as established pursuant to Section

55.03, Florida Statutes, on any invoice not paid within forty (40) calendar days until

the invoice is paid.

7. Any payment of funds under this Agreement provision will be made directly to the

Department for deposit.

IN WITNESS WHEREOF, the parties hereto have set their hands and seals on the

day and year first above written.

, STATE OF FLORIDA

LOCAL AGENCY OFFICIAL DEPARTMENT OF TRANSPORTATION

By:

Title:

By:

District Secretary

(Type Name)

ATTEST: ATTEST:

Clerk (Seal) Executive Secretary (Seal)

LEGAL APPROVAL: LEGAL APPROVAL:

LOCAL AGENCY Attorney Senior Attorney

(Type Name)

Form 140-A

Items of Work Checklist

DATE:

TO: , District Specifications

FROM: , Project Manager

COPIES TO:

SUBJECT: ITEMS OF WORK

Financial Project ID: (GOES WITH )

County (Section):

* Project Description:

The plans package for the above referenced project includes the following items of work

to be performed:

Milling & Resurfacing Highway Signing

Base Work Guardrail

Shoulder Treatment Landscaping

Drainage Improvements Box or Three-sided Culverts

Curb & Gutter Bridges

Traffic Signals MSE Walls

Lighting Sidewalks/Shared Use Path

Other (Please Specify)

Please include the county, project description and all items of work that apply in the Intent

and Scope so they may be added to the advertisement description.

* The project description should only include the road number and the limits or location

of the project.

Form 152-A

Record Shop Drawing Transmittal

Date

TO:

FROM:

(Final Review Office)

PROJECT NAME

FINANCIAL PROJECT ID

FEDERAL AID PROJECT NO.

CONTRACT ID NUMBER

COUNTY (SECTION)

STATE ROAD NUMBER

BRIDGE NUMBER

CONTRACTOR

ENGINEER OF RECORD

We are transmitting herewith the following Record Shop Drawings for archiving:

For the Final Review Office:

(Signature) (Date)

For the Receiving Office:

(Signature) (Date)

Form 233-A

Layer 3 Swi

tch Worksheet

Chassis Based Switches

Number of Management Blades

Backplane Capacity

Number of Copper Ports

Protocol Requirements

Number Fiber Ports #1

Fiber Port Speed

Number Fiber Ports #2

Fiber Port Speed

Number Fiber Ports #3

Fiber Port Speed

Number Power Supplies

Voltage (AC/DC)

Optics Needed

Optic #1

Optic #2

Optic #3

Optic #4

Optic #5

# Required

Speed Requirement

Distance Required

Require OEM

Stack Aggregation Switches

Number of Fiber Ports

Number of Copper Ports

Protocol Requirements

Number Power Supplies

Voltage (AC/DC)

Optics Needed

Optic #1

Optic #2

Optic #3

Optic #4

Optic #5

# Required

Speed Requirement

Distance Required

Require OEM

Form 240

Transportation Management Plan (TMP) Form

Responsible Professional Engineer:________________________________

FDOT Project Manager:_________________________________________

State Road: __________________________________________________

Project Location: ______________________________________________

Roadway ID: _________________________________________________

Project Limits (MP): From ____________________ to _________________

Project Description: ____________________________________________

____________________________________________________________

Financial Project ID: _____________

Federal Aid Number. ______________

FHWA Projects of Division Interest Yes No

New Const. RRR

Other _____________

In accordance with the requirements of the FDOT Design Manual (FDM) Chapter 240,

the following items determine the scope and need of a Transportation Management

Plan (TMP). Complete the following checklist and provide brief descriptions of the items

included, as appropriate.

Indicate if the project meets one or both of the following qualifying conditions as “significant

project”:

A project that, alone or in combination with other concurrent projects nearby, is

anticipated to cause sustained work zone impacts.

All Interstate system projects within the boundaries of a designated Transportation

Management Area (TMA) that occupy a location for more than three days with either

intermittent or continuous lane closures.

If either or both above qualifying conditions are met, indicate compliance with the following

documents in development of a TMP for the Project:

FDOT Design Manual

FDOT Standard Plans

FDOT Standard Specifications for Road and Bridge Construction

FDOT Basis of Estimates Manual

Manual on Uniform Traffic Control Devices for Streets and Highways, (MUTCD),

Part VI

Form 240

Policy on Geometric Design of Highways and Streets, AASHTO

Roadside Design Guide, AASHTO, Chapter 9

FDOT Accessing Transit Handbook, Chapter 4.6.

AASHTO Guide for the Development of Bicycle Facilities, 4th Edition, Chapter 7

TMP Components:

Indicate that the following TMP Components have been addressed on the project:

Temporary Traffic Control Plan (TTCP)

Work Zone Speed Established

Speed Reduction Required (Y/N)

If Yes, is the “Work Zone Speed less than Existing Posted Speed”

documentation completed (Y/N)

Lane Closure Analysis

If included, was the “Lane Closure Analysis Worksheet” and any restrictions

requiring approval completed (Y/N)

Traffic Pacing

If included, was the “Traffic Pacing Worksheet” completed (Y/N)

Portable Changeable Message Signs

If included, was the “Portable Changeable Message Sign Worksheet”

completed (Y/N)

Bicycle, Pedestrian, and Transit Accommodations

Railroads

Was the District Railroad Coordinator consulted (Y/N)

Utilities

Was the District Utility Coordinator consulted (Y/N)

Signals

Was the District Traffic Operations Engineer consulted (Y/N)

Speed and Law Enforcement Officer

Was the District Construction Office consulted or any usage requiring

approval completed (Y/N)

Form 240

Transportation Operations Plan (TOP):

Briefly describe TOP components included on the project. If a comprehensive plan has been

prepared, indicate below, and attach.

TOP Description:

___________________

___________________________________________________________________________________

Public Information Plan (PIP):

Briefly describe PIP components included on the project. If a comprehensive plan has been

prepared, indicate below, and attach.

PIP Description:

___________________

___________________________________________________________________________________

Form 243-A

Portable Changeable Message Signs Worksheet

Location of board:

Used: from at

to at

Message programme

d by:

MESSAGE 1

MESSAGE 2

Timing:

Message 1 will run: seconds.

Message 2 will r

un: seconds.

Form 243-A

Standard Abbreviations For Use On Changeable Message Signs

Standard abbreviations easily understood are:

WORD

ABBREV.

WORD

ABBREV.

Boulevard

BLVD

Normal

NORM

Center

CNTR

Parking

PKING

Crossing

XING

Pedestrian

PED

Crosswalk

XWALK

Road

Emergency

EMER

Service

SERV

Entrance, Enter

ENT

Shoulder

SHLDR

Expressway

EXPWY

Slippery

SLIP

Freeway

FRWY, FWY

Speed

SPD

Highway

HWY

Traffic

TRAF

Information

INFO

Travelers

TRVLRS

Left

LFT

Warning

WARN

Maintenance

MAINT

Other abbreviations are easily understood whenever they appear in conjunction with a particular

word commonly associated with it. These words and abbreviations are as follows:

WORD ABBREV. PROMPT

Access ACCS Road

Ahead AHD Fog*

Blocked BLKD Lane*

Bridge BRDG [Name]*

Chemical CHEM Spill

Construction CONST Ahead

Exit EX, EXT Next*

Express EXP Lane

Hazardous HAZ Driving

Interstate I [Number]

Major MAJ Accident

Mile MI [Number]*

Minor MNR Accident

Minute(s) MIN [Number]*

Oversized OVRSZ Load

Prepare PREP To Stop

Pavement PVMT Wet*

Quality QLTY Air*

Route RT Best*

Turnpike TRNPK [Name]*

Vehicle VEH Stalled*

Cardinal Directions N, E, S, W [Number]

Upper, Lower UPR, LWR Level

* = Prompt word given first

Form 243-A

The following abbreviations are understood with a prompt word by about 75% of the

drivers. These abbreviations may require some public education prior to usage.

WORD

ABBREV.

PROMPT

Condition

COND

Traffic*

Congested

CONG

Traffic

Downtown

DWNTN

Traffic

Frontage

FRNTG

Road

Local

LOC

Traffic

Northbound

N-BND

Traffic

Roadwork

RDWK

Ahead [Distance]

Temporary

TEMP

Route

Township

TWNNSHP

Limits

* = Prompt word given first

Certain abbreviations are prone to inviting confusion because another word is abbreviated

or could be abbreviated in the same way. DO NOT USE THESE ABBREVIATIONS:

ABBREV.

INTENDED WORD

WORD ERRONEOUSLY GIVEN

WRNG

Warning

Wrong

ACC

Accident

Access (Road)

DLY

Delay

Daily

Light (Traffic)

Left

STAD

Stadium

Standard

Left

Lane (Merge)

PARK

Parking

Park

RED

Reduce

Red

POLL

Pollution (Index)

Poll

FDR

Feeder

Federal

LOC

Local

Location

TEMP

Temporary

Temperature

CLRS

Clears

Color