JSTM: 21-Fm-006

• CONDUCTED ON:

  Date

• WORK ORDER / SERVICE REQUEST NUMBER:

• WORK ACTIVITY:

• LOCATION:
  Address

• ROAD NAME:

• ROAD ADDRESS FROM TO (IF APPLICABLE):

Responsible Person

• LCC RESPONSIBLE PERSON:

• Name:

• CONTRACTOR BUSINESS NAME:

• Name:

• CONTRACTOR RESPONSIBLE PERSON:

• Name:

Type of Work Site

• Static

  Yes

  No

• Mobile

  Yes

  No

• Frequently Changing

  Yes

  No

• Urban

  Yes

  No

• Rural

  Yes

  No

• Short Term (1 day)

  Yes

  No

• Long Term

  Yes

  No

• High Volume (>1500 Vpd)

  Yes

  No

• Low Volume

  Yes

  No

Details

• LCC Traffic Management Plans Used (EditionNumber CTMP23052013 / Plan):

  Yes

  No

• Plan Number:

• SIte Specific Traffic Management Plan Used:

  Yes

  No

• Plan Number:

• Traffic Management Plan:

  Media

• Time that signs are installed:

  Date

• Are all works covered by signage area?

  Yes

  No

  NA

• Are all unrelated signs within work area covered or obscured?

  Yes

  No

• Are all approach routes to work site appropriately signed?

  Yes

  No

• Drive through work site to check effectiveness:

  Yes

  No

• Are there any time restrictions for work in this area?

  Yes

  No

• If yes enter time:

  Date

• Monitor traffic flow through the work site. If any delays or unexpected problems are observed, modify plan to resolve; or cease work, remove traffic control and report to Manager immediately:

• Comment:

• If work site is changing, signage is regularly adjusted:

• Comment:

• Check all signs are removed from the short term site at the completion of works:

  Yes

  No

• Time that signs are removed:

  Date

• Speed zone reapplied at end of works:

  Yes

  No

  NA

After Hours Signage

• Time that after hours signs are installed:

  Yes

  No

• If yes enter time:

  Date

• Weather conditions:

  Select Fine Fog Wet Over Cast Dust Windy Light Rain Smoke Other

  • Fine
  • Fog
  • Wet
  • Over Cast
  • Dust
  • Windy
  • Light Rain
  • Smoke
  • Other

• If Other then enter details

• Signage changes due to weather and / or site conditions:

  Yes

  No

• If yes enter time:

  Date

• Sketch diagram of signs left for after care:

  Drawing

• Comments:

• Who left signs out:

• Name:

  Sign

Complete and Sign

• Further comments:

• Responsible LCC Employee OR Contractor:

  Sign

• Date:

  Date

• Responsible LCC Supervisor:

  Sign

• Date:

  Date

Email Completed Analysis To: remount road.admin@launceston.tas.gov.au