Schedule D- forms.pdf

Michigan Department of Transportation

1577 (10/04)

TRAFFIC SIGNAL TIMING RECORD

Information required by Act 51 of 1951, as documentation for potential litigation.

COMPLETE AND RETURN

FILE REF. LOCATION

Timing installed as authorized by permit dated.

DATE INSTALLED

Timing NOT installed as authorized. Copy of corrected permit enclosed.

Explanation:

TIMING PERMIT IN CONTROLLER INSTALLED BY

Michigan Department of Transportation

1577 (10/04)

TRAFFIC SIGNAL TIMING RECORD

Information required by Act 51 of 1951, as documentation for potential litigation.

COMPLETE AND RETURN

FILE REF. LOCATION

Timing installed as authorized by permit dated.

DATE INSTALLED

Timing NOT installed as authorized. Copy of corrected permit enclosed.

Explanation:

TIMING PERMIT IN CONTROLLER INSTALLED BY

Michigan Department of Transportation

1577 (10/04)

TRAFFIC SIGNAL TIMING RECORD

Information required by Act 51 of 1951, as documentation for potential litigation.

COMPLETE AND RETURN

FILE REF. LOCATION

Timing installed as authorized by permit dated.

DATE INSTALLED

Timing NOT installed as authorized. Copy of corrected permit enclosed.

Explanation:

TIMING PERMIT IN CONTROLLER INSTALLED BY

Michigan Department of Transportation

1577 (10/04)

TRAFFIC SIGNAL TIMING RECORD

Information required by Act 51 of 1951, as documentation for potential litigation.

COMPLETE AND RETURN

FILE REF. LOCATION

Timing installed as authorized by permit dated.

DATE INSTALLED

Timing NOT installed as authorized. Copy of corrected permit enclosed.

Explanation:

TIMING PERMIT IN CONTROLLER INSTALLED BY

TRAFFIC & SAFETY DIVISION

TRAFFIC SIGNALS UNIT

PO BOX 30050

NO POSTAGE

NECESSARY

IF MAILED

IN THE

UNITED STATES

BUSINESS REPLY MAIL

FIRST-CLASS MAIL LANSING, MIPERMIT NO. 1312

POSTAGE WILL BE PAID BY ADDRESSEE

MICHIGAN DEPARTMENT OF TRANSPORTATION

LANSING MI 48909-9791

PO BOX 30050

NO POSTAGE

NECESSARY

IF MAILED

IN THE

UNITED STATES

BUSINESS REPLY MAIL

FIRST-CLASS MAIL LANSING, MIPERMIT NO. 1312

POSTAGE WILL BE PAID BY ADDRESSEE

PO BOX 30050

NO POSTAGE

NECESSARY

IF MAILED

IN THE

UNITED STATES

BUSINESS REPLY MAIL

FIRST-CLASS MAIL LANSING, MIPERMIT NO. 1312

POSTAGE WILL BE PAID BY ADDRESSEE

PO BOX 30050

NO POSTAGE

NECESSARY

IF MAILED

IN THE

UNITED STATES

BUSINESS REPLY MAIL

FIRST-CLASS MAIL LANSING, MIPERMIT NO. 1312

POSTAGE WILL BE PAID BY ADDRESSEE

ELECTRICAL DEVICES

of Transportation TROUBLE REPORT 0499 (10/00) JOB REPORT NO.PRINT LEGIBLY. This form does not need to be typewritten.

Use reverse for additional REMARKS/DESCRIPTION if necessary.

REFERENCE NO.LOCATION

TIME CALL RECEIVEDREPORTED BY: DATEA.M.

PM.

TIME ELECTRICIAN NOTIFIED TRUCK NO. ACCIDENT INVOLVEDTOTAL TRAVEL TIMETIME ARRIVED TIME COMPLETED

A.M.A.M.A.M. NOYES

PM.PM.PM.

TYPE ( One)

SIGNAL

FLASHER

KEEP RIGHT

O'HEAD LUMIN.

OTHER

REMARKS

DESCRIPTION OF WORK PERFORMED

ELECTRICIAN(S) (SIGNATURE) DATE

REPORT APPROVED BY (SIGNATURE) DATECALL RECEIVED BY:

TROUBLE

RED

OUT

YELLOW

OUT

GREEN

OUT

NO

COLOR

DON'T WALK

OUT

WALK

OUT

SIGNAL in

FLASH

POWER

FAILURE

TIMING

PROBLEM

SIGNAL

LOW

OTHER

(NOTE IN REMARKS)

REPORTED

FOUND

ELECTRICAL DEVICES

Michigan Department of Transportation TROUBLE REPORT 0499 (10/00) JOB REPORT NO.PRINT LEGIBLY. This form does not need to be typewritten.

Use reverse for additional REMARKS/DESCRIPTION if necessary.

REFERENCE NO.LOCATION

TIME CALL RECEIVEDREPORTED BY: DATEA.M.

PM.

TIME ELECTRICIAN NOTIFIED TRUCK NO. ACCIDENT INVOLVEDTOTAL TRAVEL TIMETIME ARRIVED TIME COMPLETED

A.M.A.M.A.M. NOYES

PM.PM.PM.

TYPE ( One)

SIGNAL

FLASHER

KEEP RIGHT

O'HEAD LUMIN.

OTHER

REMARKS

DESCRIPTION OF WORK PERFORMED

ELECTRICIAN(S) (SIGNATURE) DATE

REPORT APPROVED BY (SIGNATURE) DATECALL RECEIVED BY:

TROUBLE

RED

OUT

YELLOW

OUT

GREEN

OUT

NO

COLOR

DON'T WALK

OUT

WALK

OUT

SIGNAL in

FLASH

POWER

FAILURE

TIMING

PROBLEM

SIGNAL

LOW

OTHER

(NOTE IN REMARKS)

REPORTED

FOUND

SIGN SIGNAL OR

PAVEMENT MARKING JOB REPORT

Michigan Department of Transportation

0489 (10/00)

DIVISION WORK ORDER NO. REFERENCE NO. REGION COUNTY

MUNICIPALITY INTERSECTION OF:REQUESTED BY:

DATE JOB STARTED DATE JOB FINISHED IN SERVICE APPLICATION

DESCRIPTION OF

ARTICLES OR

SERVICES RENDERED

MATERIALS UNIT COST AMOUNT LABOR COSTSQUANTITY

EMPLOYEE HOURS RATE AMOUNT

LABOR TOTAL

EQUIPMENT COSTS

HOURS RATE AMOUNTEQUIPMENT NO.

TRAVEL EXPENSE: EQUIPMENT TOTAL

MATERIAL TOTAL GRAND TOTAL

SIGN AND SIGNAL SUPERVISOR APPROVAL DATE

AGY AY INDEX

NO.

PCA

NO.

AGENCY

OBJ. GRANT PH PROJ. PH AG1 AG2 AG3 AMOUNT

REPORT OF DEPARTMENT PROPERTY DAMAGE

Information required by Act 17, P.A. of 1925.

Failure to supply this information will result in non-payment for service.

ACCIDENT/INCIDENT REPORT NUMBER OWNER/DRIVER ACCIDENT DATE

TRUNKLINE NUMBER POLICING AGENCY

AGENCY MAKING REPAIRS (List all agencies involved) CONTACT PERSON AGENCY PHONE NO.

WORK COMPLETED, CHECK APPROPRIATE BOX:

Repair guardrail, Total guardrail length _______________ft Repair sign Other repair _____________________________________ Replacement of entire guardrail system Total sign replacement Other total replacement ____________________________

CHECK

APPROPRIATE

BOX:

Repairs/replacement to damage caused by the above accident have been completed.

The cost is itemized below.

Below is an estimated cost of damage caused by the accident above.

Estimate previously reported.

INSTALLER BY SHOP IDENTIFIER NUMBER DATES WORKED HOURS RATE

DIRECT LABOR

CHARGES

L ab or

DIRECT LABOR COST TOTAL

NUMBER OR DESCRIPTION DATES WORKED HOURS RATE

DIRECT EQUIP.

E qu ip m en t

DIRECT EQUIPMENT COST TOTAL

ITEM DESCRIPTION UNIT COST/UNIT

DIRECT

MATERIAL

M at er ia ls

DIRECT MATERIAL COST TOTAL

TOTAL DIRECT COSTS

INDIRECT COSTS

LABOR ADDITIVE (fringe) % % x DIRECT LABOR COST TOTAL =

MATERIAL HANDLING % % x DIRECT MATERIAL COST TOTAL =

OVERHEAD % % x TOTAL DIRECT COSTS =

TOTAL INDIRECT COSTS

TOTAL COST (TOTAL DIRECT COSTS + TOTAL INDIRECT COSTS)

TO BE FILLED OUT BY ARU ONLY

SIGNATURE

LESS DEPRECIATION (On Replacement Cost Only) $

TITLE

MAIN OFFICE CHARGE $

DATE

GRAND TOTAL $

of Transportation

0443 (02/08)

DISTRIBUTION:

REGION MAINT. ENGR.

YOUR FILES

0443 (02/08) ADDITIONAL PAGE MAY BE USED IF NEEDED

ACCIDENT/INCIDENT REPORT NUMBER OWNER/DRIVER ACCIDENT DATE

DESCRIPTION OF ARTICLES OR SERVICE RENDERED

INSTALLER BY SHOP IDENTIFIER NUMBER DATES WORKED HOURS RATE

DIRECT LABOR

La bo r

ENTER TOTAL ON PAGE ONE

NUMBER OR DESCRIPTION DATES WORKED HOURS RATE

DIRECT EQUIP.

E qu ip m en t

ENTER TOTAL ON PAGE ONE

MDOT

MDOT ADDITIONAL PAGE MAY BE USED IF NEEDED

ACCIDENT/INCIDENT REPORT NUMBER OWNER/DRIVER ACCIDENT DATE

ITEM DESCRIPTION UNIT COST/UNIT

DIRECT

MATERIAL

M at er ia ls

ENTER TOTAL ON PAGE ONE

0443 (02/08)

Reference Guide for completing Michigan Department of Transportation Report of Department Property Damage Form 443

• The calculations are automatic when the form is completed on line.

• Make sure you sign the form and include your title and the date.

• A new section has been added which is to be completed by MDOT’s Accounts

Receivable Unit.

ACCIDENT/INCIDENT REPORT NUMBER - Can be found in the upper right corner of the

Traffic Crash Report.

OWNER/DRIVER – Can be found in the center of the Traffic Crash Report.

ACCIDENT DATE - Can be found in the upper left corner of the Traffic Crash Report.

TRUNKLINE NUMBER - Can be found in the center of the Traffic Crash Report.

POLICING AGENCY - Can be found in the top middle of the Traffic Crash Report.

AGENCY MAKING REPAIRS - The garage or the County Road Commission making the repairs.

CONTACT PERSON - Supervisor overseeing trunkline repairs that can answer any questions regarding the items that were filled out on form 443.

AGENCY PHONE NUMBER - The garage phone number or county road commission phone number where the contact person can be reached.

WORK COMPLETED, CHECK APPROPRIATE BOX

-Repair Guardrail – a guardrail is repaired when less than the whole guardrail is being replaced. (Example: Only one tri-beam rail used)

- If this is a guardrail repair, what is the total length of the entire guardrail from end to end, including, the part that was repaired.

-Replacement of entire Guardrail – a guardrail is replaced when the whole guardrail is taken down from end to end and replaced with all new guardrail.

-Repair Sign – a sign is repaired when only a portion has to be replaced (Example: The post is replaced but the original sign is reinstalled).

-Total sign Replacement – a sign is replaced when the sign itself is taken down and replaced with a new sign (Example: The post(s), sign, nuts and bolts are totally replaced).

-Other Repair – Would include repairs to traffic signals, bridges, driveways, traffic control, clean-up cost, etc., but would not include signs or guardrails.

-Other total Replacement – Would include total replacement of traffic signals, bridges, etc., but would not include signs or guardrails.

Check Appropriate Box: Check only one box.

Repairs/replacement to damage caused by the above accident have been completed. The cost is itemized below.

Or Below is an estimated cost of damage caused by the accident above.

Or Estimate previously reported.

MDOT 0443 (02.08)

Labor INSTALLER BY SHOP INDENTIFIER - Employee number, Installers initials, or

TMW number as long as the information on the 443 form can be identified to a specific individual. This will reduce the number of harassing phone calls to these individuals.

DATES WORKED - These would be all the dates you were at this site.

HOURS - This would be the hours you were at the site.

RATE - This is the hourly rate including benefits.

DIRECT LABOR CHARGES - Hours worked multiplied by rate equals direct labor charges.

DIRECT LABOR COST TOTAL – Total of all direct labor charges.

Equipment NUMBER OR DESCRIPTION - Equipment number or description.

DATES WORKED - The date the equipment was at the job site.

HOURS - Hours worked on site.

RATE - Equipment rental rate which is recalculated annually.

DIRECT EQUIPMENT CHARGE - Hours multiplied by rate equals direct equipment

DIRECT EQUIPMENT COST TOTAL – Total of all direct equipment charges.

Materials ITEM DESCRIPTION - Description if the item(s) used for the repair or replacement.

UNIT - The number of units used on this particular job.

COST/UNIT - Cost of one unit.

DIRECT MATERIAL CHARGES - Units multiplied by cost per unit equals direct material charges.

DIRECT MATERIAL COST TOTAL – Total of all direct material charges.

TOTAL DIRECT COST- Add direct labor charges plus direct equipment charges plus direct material charges equals total direct cost.

Indirect Costs

LABOR ADDITIVE - Multiply Labor Additive rate by direct labor charges.

* County Road Commission - refer to State Trunkline Maintenance Contract.

MATERIAL HANDLING - Multiply material handling charge percentage times total direct material charges to equal the indirect material charges.

*MDOT repair facilities do not charge a handling fee. Only County Road Commissions have handling charges as established in contract agreement.

OVERHEAD – Multiply overhead rate by the direct costs.

*For County Road Commission, the overhead rate is set by the county according to a formula in the State Trunkline Maintenance Contact.

TOTAL INDIRECT COST - Total of indirect labor charges plus indirect material charges plus indirect cost for overhead

TOTAL COST TO REPAIR/REPLACE -Total of the direct charges plus the total indirect

**Additional pages can be added to include more space for Labor, Equipment and Materials and a description of articles or service rendered. See additional pages online.

SIGNATURE – Individual completing form.

TITLE – Job title of individual completing form.

MDOT 0443 (02/08)

PO BOX 30050

NO POSTAGE

NECESSARY

IF MAILED

IN THE

UNITED STATES

BUSINESS REPLY MAIL

FIRST-CLASS MAIL LANSING, MIPERMIT NO. 1312

POSTAGE WILL BE PAID BY ADDRESSEE

PO BOX 30050

NO POSTAGE

NECESSARY

IF MAILED

IN THE

UNITED STATES

BUSINESS REPLY MAIL

FIRST-CLASS MAIL LANSING, MIPERMIT NO. 1312

POSTAGE WILL BE PAID BY ADDRESSEE

PO BOX 30050

NO POSTAGE

NECESSARY

IF MAILED

IN THE

UNITED STATES

BUSINESS REPLY MAIL

FIRST-CLASS MAIL LANSING, MIPERMIT NO. 1312

POSTAGE WILL BE PAID BY ADDRESSEE

PO BOX 30050

NO POSTAGE

NECESSARY

IF MAILED

IN THE

UNITED STATES

BUSINESS REPLY MAIL

FIRST-CLASS MAIL LANSING, MIPERMIT NO. 1312

POSTAGE WILL BE PAID BY ADDRESSEE