Qualified Traffic Control Equipment Submission Form for
Traffic Signal Controller Cabinet Hardware and Components
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
Address
City, State ZIP
Phone
Email
Part B. Basic Product Information
Name or Model #
Description
Link to product cutsheet
Product Type
Communication Device
Load Switch
Bus Interface Unit
Other:
Battery Backup System/UPS
Flash Transfer Relay
Power Supply
Part C. Technical Product Information
Technical Notes (if necessary):
Application Revision: November 3, 2014
Qualified Traffic Control Equipment: http://goo.gl/OS7o5N
Cabinet Hardware and Components Application
Page 1 of 3
Part D. Product Use
Has this product, or one similar, been previously submitted to MassDOT?
If Yes, please explain:
Yes
No
Is this a replacement product for one currently approved by MassDOT?
If Yes, please explain:
Yes
No
Is this product currently in use in Massachusetts?
If Yes, please explain:
Yes
No
Yes
No
Yes
No
State DOTs that have
approved this product:
Is this product in commercial production?
If Yes, for how long?
If No, please explain:
Have there been any recalls on this product?
If Yes, please explain:
Recommended Routine Maintenance Program (if applicable):
Warranty Information:
Application Revision: November 3, 2014
Qualified Traffic Control Equipment: http://goo.gl/OS7o5N
Cabinet Hardware and Components Application
Page 2 of 3
Contact
Company
Supplier/
Website
Distributer
Address
Email
Contact
Company
Manufacturer Website
Address
Email
Contact
Reference #1 Agency
Email
Contact
Reference #2 Agency
Email
Part E. Contact Information
Title
City, State ZIP
Phone
Title
City, State ZIP
Phone
Title
Phone
Title
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
Qualified Traffic Control Equipment: http://goo.gl/OS7o5N
Cabinet Hardware and Components Application
Page 3 of 3