Title Page
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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MDT Inspector
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District
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Crew/ Section
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Contractor
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On-site Supervisor Job Title
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MDT Representative
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Weather and Other Conditions
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Route Name and Number (ie: I-90/15 Interchange)
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Nearest Mile Marker
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Work Zone Type
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Road Type
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Direction
- EB
- WB
- NB
- SB
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Work Location
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Speed MPH
- <45
- 45
- 50
- 55
- 60
- 65
- 70
- 75
- 80
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Special Conditions
- Urban
- Railroad Crossing
- Rural
- School Zone
- Night Time Work
- Curve
- Intersections
- Hilly
- Ramp Lane
- Bridge
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Work Zone Description
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Job Safety Briefing
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Proper PPE Worn
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Equipment is in Proper Working Order
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Employees Trained
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All Policies & Procedures are being Followed
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Advanced Warning Signs
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Advanced Warning Placement
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Channelizing Devices
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Channelizing Device Spacing
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Channelizing Taper
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Channelizer Conditions
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Buffer Area Spacing (Based on speed) 20MPH-115ft, 25MPH-155ft, 30MPH-200ft, 35MPH-250ft, 40MPH-305ft, 45MPH-360ft, 50MPH-425ft, 55MPH-495ft, 60MPH-570ft, 65MPH-645ft, 70MPH-730ft, 75MPH-820ft.
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Crash Attenuator in proper position
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Does work area pose an adverse affect on Traffic?
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Arrow Board Placement
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Arrow Board Illumination
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Flagger Position
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Flag Paddle or Flag Condition
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Signature of Inspector
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Select date
