Submittal Form for Crashworthiness Evaluation of Roadside Device

Submittal Form for Crashworthiness Evaluation of Roadside Device
Please complete all statements.
Product Name*
Manufacturer*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Local Distributor*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Recommended uses*
Is device sacrificial?*
If not sacrificial, what % of initial cost is necessary for repair to initial status?
Material Specifications Furnished by Manufacturer?*

YesNoTo be Mailed
Plans, Sketches, Etc. Furnished by Manufacturer?*

YesNoTo be Mailed
Instructions for Installation Available?*

YesNoTo be Mailed
Does product meet requirements of any of the following specifications? Provide specification number(s) and include the referenced documents as attachments along with this form)
AASHTO
ASTM
Fed. Spec.
ARDOT
Other
If other, please specify
Referenced Documents

File types: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
Cancelof
10. Is product approved for use by other highway authorities or other agencies? (State by whom used and whether use is routine or experimental only)*
Product Data
Date Product First Introduced to Market*

MonthDayYear
Date
Meets Specifications (check all that apply)*

MASH 2016NCHRP 350MASH 2009
Other State DOTs in Use or Testing
State
Contact
Phone
State
Contact
Phone
State
Contact
Phone
Materials Enclosed (check all that apply)*

AASHTO MASH 2016 Test ReportPhysical SamplePhotographsProduct Technical Data SheetsNTPEP Test ReportState or Federal Agency Test ReportsIndependent Laboratory Test ReportsOther
STATEMENT OF CONDITIONS FOR CRASHWORTHINESS EVALUATION OF ROADSIDE DEVICE

I. Acceptance of a product for evaluation by the ARDOT is in no way a commitment to purchase, recommend, or specify the product investigated regardless of its performance.

II. Data resulting from an evaluation of the submitted product is public information and will not be considered privileged. As authorized by the signature below, all information developed during this product evaluation may be released by the Arkansas Department of Transportation at its discretion.

I certify that all the information regarding the product listed herein and included with this application is true, complete, and accurate:
Supplier's Authorizing Agent (Signature)*

Clear
Title*
Date*

MonthDayYear
Date
Crash test laboratories used to support a request for an ARDOT implementation must be properly accredited. See 23 CFR 637.209(a5) from FHWA. Any crash test reports submitted to support a request for ARDOT implementation must include a statement from the accredited laboratory that certifies the testing was conducted in conformity with AASHTO MASH 2016 criteria.

Form Date: 11/2022

Revision Date:
Should be Empty:

Submittal Form for Crashworthiness Evaluation of Roadside Device

Product Data