PennDOT GLG Project Scoping Form

(10-26)

www.pa.gov/penndot

Green Light-Go Project
Pre-Application Scoping Form

A - Project Overview
County	Primary Municipality	District

Project Name

Project Type (check one)

LED Replacement

Traffic Signal Retiming

Study and Removal of Unwarranted Traffic Control Signals

Monitoring

Innovative Technologies

Communications/Connections back to Traffic Management Center (TMC)

Detection and/or Controller Upgrades

Modernization

Intelligent Transportation System (ITS) Applications

Traffic Signal Technologies

Project Complexity (check one)

Level 0 - Retiming Limited to timing/phasing modifications which are accomplished with existing equipment

Level 1 - Equipment Upgrades Replacement, upgrade, or addition of traffic signal equipment which does not impact information shown on the traffic signal permit condition diagram

Level 2 - Minor Alterations Modifications to items shown on the traffic signal permit condition diagram, but does not include replacement or installation of traffic signal supports

Level 3 - Major Alterations Modifications to the traffic signal which include replacement or addition of traffic signal poles, but retain some existing traffic signal equipment

Level 4 - New Construction Full modernization/replacement of all traffic signal equipment at an existing signalized intersection

Project Description (include narrative to describe the project scope of work)

Why is the project Needed? (Provide project needs that are tangible and fact-based, framed in terms of problems and deficiencies, and how the proposed solution will address these problems and deficiencies)

What is the Project Purpose?

Are private properties impacted? (Indicate if the project will require any property acquisition, such as for signal equipment/poles or curb ramps. Indicate if the project will impact any properties, such as driveway configuration changes. If there are any property impacts, indicate how many properties.)

Are utilities impacted? (Indicate if any overhead or underground utility impacts are anticipated. If the project includes communications, indicate if attachment to utility poles are anticipated and if coordination has begun.)

Additional Information (Describe any additional information that helps to justify the project)

B - Project Location

+ Add Signal

C - Cost Estimate
Construction Phase Detailed Estimate

+ Add Standard Construction Item + Add Custom Construction Item

Cost Estimate Summary
Traffic Signal Items
950	General Traffic Signal Items
951	Traffic Signal Supports
952	Controller Assembly
953	Traffic Signal Systems and Communications
954	Electrical Distribution
955	Signal Heads
956	Detectors
957	Advanced Traffic Signal Technology
Signing and Pavement Marking
93x	Signs
96x	Pavement Markings
Other Items
	Roadway Items
	Subtotal
%	Mobilization (Lump Sum)
%	Maintenance and Protection of Traffic (Lump Sum)
	Subtotal
%	Cost Escalation
	Total Construction Phase
Other Phases
%	Engineering/Design/Inspection
	Utilities
	Right-of-Way
Total Project Cost
	Total Project Cost
	Minimum Matching Funds Required (20%)
Grant Funding Request
		Requested Funding	Municipal Match
Municipal Match %	Total

To submit this form, click "Save" and then attach the file to an email and send to GLG@pa.gov.

D - PennDOT Review
To be completed by PennDOT
Review Comments
Project Type (check one) Publication 9 Publication 740 PennDOT Design

Reviewer

Date