Federal-Aid Eligibility Letter Request

OMB Control #: 2125-XXXX

Expiration Date: MM/DD/YYYY

The Department of Transportation (DOT)

Federal Highway Administration (FHWA)

Request for Federal Aid Reimbursement Eligibility of

Safety Hardware Devices

Paperwork Reduction Act Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number. The OMB Control Number for this information collection is 2125-XXXX. Public reporting for this collection of information is estimated to be approximately (X) minutes per response, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, completing, and reviewing the collection of information.

All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Department of Transportation, Federal Highway Administration, 1200 New Jersey Ave SE, Washington, D.C. 20590.

Date: (autofill)

Requestor Information (The Requestor is the person who is responsible for the request of the device)

Requestor name: (first name, last name)

Affiliation:

Address: (street, City, State, Country)

Hardware Device Information

Hardware Device Type: (drop-down options: Barriers, Terminals and Crash Cushions, Truck- and Trailler-Mounted Attenuators, Support Structures, Work-Zone Traffic Control Devices, Breakaway Utility Poles, Longitudinal Channelizers)

Hardware Name:

Testing Criterion: (drop-down options: MASH 2016)

Test Level: (drop-down options: vary based on device type)

Disclosure of Financial Interest

Enter all disclosures of financial interests as required by the FHWA “Federal-aid Reimbursement Eligibility Process for Safety Hardware Devices”

Device Description

Enter device description as tested.

Crash Testing

Crash test facility name:

Address: (street, City, State, Country)

Accreditation Certificate: (please attach the certificate which covers the period of the crash tests and the certificate most current.)

Engineer Name:

Description of crash tests and results:

MASH Recommended Test, Test Description, How Evaluation Criterion being met, Results

Signatures

Engineer’s signature:

By signing this request, I confirm that the device(s) was (were) tested in conformity with the AASHTO Manual for Assessing Safety Hardware 2^nd Edition (2016) (MASH) and that the test results meet the evaluation criteria in the MASH.

Requestor’s signature:

By submitting this request for review and evaluation by the Federal Highway Administration, I certify that the device(s) was (were) tested in conformity with the AASHTO Manual for Assessing Safety Hardware 2^nd Edition (2016) (MASH) and that the test results meet the evaluation criteria in the MASH.

Attachments

Please upload all other supporting documents.