National Work Zone Memorial Name Submission Form

National Work Zone Memorial Name Submission Form

Respect and Remembrance: Reflections of Life on The Road

INSTRUCTIONS
A memorial name submission form must be submitted for each name to be considered for inclusion on the National Work Zone Memorial.
NAME SUBMISSION DEADLINE
Names are inscribed on the National Work Zone Memorial once a year, prior to ATSSA’s Convention & Traffic Expo. A name submission form must be submitted by Dec. 1 to be considered for inclusion on the Memorial the following year.
QUESTIONS?
Contact ATSS Foundation at foundation@atssa.com or 540-368-1701.
INFORMATION ON DECEDENT
Full Name (as name should appear on the Memorial)*
Date of Incident*

MonthDayYear
Date
Date of Death*

MonthDayYear
Date
Location of Fatality (City and State)*
The Person Named Above (fatality must have occurred in an active roadway work zone*) is a:*

ChildLaw EnforcementMotoristPedestrianPublic Safety OfficialWork Zone Worker
Brief Description of Work Zone Incident*
*Criteria: A work zone is defined in the Manual on Uniform Traffic Control Devices (MUTCD) as an area of a roadway with construction, maintenance or utility work activities. Work zones are typically marked by signs, channelizing devices, barriers, pavement markings and/or work zone vehicles. The zone extends from the first warning sign or high-intensity rotating, flashing, oscillating or strobe lights on a vehicle to the “End Road Work” sign or the last temporary traffic control device.
FORMER EMPLOYER INFORMATION OF THE DECEASED
Employer Name*
Street Address*

Street Address

Street Address Line 2

CityState

Zip Code
Contact Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.

FAMILY CONTACT INFORMATION

(must obtain permission from the deceased’s family)
Have you obtained permission from the deceased's family to proceed?*

Yes, I have obtained permission from deceased's family.No, I was unable to obtain permission from deceased's family.
Family Member Contact Name*

First NameLast Name
Relation to The Deceased*
Street Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email address*
example@example.com
Phone Number*
Please enter a valid phone number.
Does the decedent have dependents (spouse and/or children)?*

YesNo
If yes, Spouse’s Name

First NameLast Name
If yes, Number of Children
Ages of Children (if available)
*ATSS Foundation has resources for families including the Roadway Worker Memorial Scholarship and Chuck Bailey Memorial Scholarship program (post-high school education scholarships) and the Experience Camps Travel Scholarship program (summer camps for grieving children).

Include at least one of the following required documents to verify that the incident occurred within a work zone.*

Official police incident reportNews article regarding incident/deathNotarized employer affidavit, applicable only for roadway workers, law enforcement officers, and emergency workers.
File Upload: Official police incident report*

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File Upload: News article regarding incident/death*

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File Upload: Notarized employer affidavit, applicable only for roadway workers, law enforcement officers, and emergency workers.*

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PHOTOGRAPH REQUIREMENTS
*Required*
Select a high-resolution photo of person to be honored. Save the photo file in a PNG or JPG format before uploading it to the site. Please avoid using black and white images.

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APPLICANT’S INFORMATION
I certify I have obtained permission from the deceased’s family or former guardian to provide the above information, and for the deceased’s name to be listed on the National Work Zone Memorial. By providing this information, applicant shall indemnify and save and hold harmless American Traffic Safety Services Association (ATSSA), the American Traffic Safety Services Foundation (ATSS Foundation) and its officers, agents and employees acting for ATSSA or ATSS Foundation, against any liability, including costs and expenses.
I Certify to the Terms Above
I further certify that all information provided is true and correct to the best of my knowledge, particularly, the spelling of the decedent’s name, as it will appear on the National Work Zone Memorial.
I Certify to the Terms Above
I further certify that the individual named on this form was not under the influence of drugs or alcohol at the time of the fatality.
I Certify to the Terms Above
Signature*

Clear
Date of Application*

MonthDayYear
Date
Name of Applicant*

First NameLast Name
Relation to the Deceased*
Organization (if applicable)
Email address*
example@example.com
Phone Number*
Please enter a valid phone number.
Should be Empty:

INSTRUCTIONS

NAME SUBMISSION DEADLINE

QUESTIONS?

INFORMATION ON DECEDENT

FORMER EMPLOYER INFORMATION OF THE DECEASED

FAMILY CONTACT INFORMATION

PHOTOGRAPH REQUIREMENTS

APPLICANT’S INFORMATION