TAURANGA CITY COUNCIL - Site Condition Rating Form

• Site

  Attended

  Unattended

• STMS Name/No.

• Mobile

• TM Company

• Contractor

• Date

  Date

• Road Level

• Location
  Address

General Information

• WAP Ref.

• Activity

Signs

• A1. Missing

  No

  Yes

  N/A

• A2. Position

  No

  Yes

  N/A

• A3. Not visible/Fallen Over

  No

  Yes

  N/A

• A4. Wrong Sign

  No

  Yes

  N/A

• A5. Condition Unacceptable

  No

  Yes

  N/A

• A6. Permanent Sign

  No

  Yes

  N/A

• A7. Unapproved Sign Used/Too Small

  No

  Yes

  N/A

• A8. Non-compliant support/Sign too low

  No

  Yes

  N/A

Mobile/Semi Static

• B1. Tail pilot vehicle/AWVMS omitted or incorrect location

  No

  Yes

  N/A

• B2. Lead pilot vehicle omitted or incorrect location

  No

  Yes

  N/A

• B3. Shadow vehicle omitted or incorrect location

  No

  Yes

  N/A

• B4. TMA missing or non-compliant

  No

  Yes

  N/A

• B5. AWVMS/arrowboard non-compliant

  No

  Yes

  N/A

Pedestrians/Cyclists

• C1. Inadequate provision of pedestrians

  No

  Yes

  N/A

• C2. Inadequate provision of cyclists

  No

  Yes

  N/A

Delineation

• D1. Missing or ineffective taper

  No

  Yes

  N/A

• D2. Tapers too short

  No

  Yes

  N/A

• D3. Taper too short or missing

  No

  Yes

  N/A

• D4. Spacing in taper

  No

  Yes

  N/A

• D5. Spacing along lanes

  No

  Yes

  N/A

• D6. Missing or ineffective delineation along lanes

  No

  Yes

  N/A

• D7. Condition unacceptable

  No

  Yes

  N/A

• D8. Using non-approved device

  No

  Yes

  N/A

• D9. Road marking incorrect at long term level 2 or 3 roads

  No

  Yes

  N/A

• D10. Inadequate/missing site access

  No

  Yes

  N/A

Miscellaneous

• E1. Working in live lanes

  No

  Yes

  N/A

• E2. Missing or ineffective controller

  No

  Yes

  N/A

• E3. Safety zone compromised

  No

  Yes

  N/A

• E4. High visibility garment not acceptable

  No

  Yes

  N/A

• E5. Marginal surface condition (carriageway only)

  No

  Yes

  N/A

• E6. Unacceptable surface condition (peds, cyclists or carriageway)

  No

  Yes

  N/A

• E7. Barrier defects (missing or incorrect components)

  No

  Yes

  N/A

• E8. Unsafe of redundant TTM

  No

  Yes

  N/A

• E9. VMS message incorrect/inappropriate

  No

  Yes

  N/A

• E10. Flashing beacons/indicator lights not used or ineffective

  No

  Yes

  N/A

• E11. Parking/stopping features not relocated

  No

  Yes

  N/A

• E12. Unsafe and illegal parking of plant/equipment

  No

  Yes

  N/A

• E13. Marginal items (signs, delineators, Hi Vis garments)

  No

  Yes

  N/A

Other Worksite Aspects

• G1. Qualified person on site (refer to A5 of CoPTTM)

  Yes

  Unacceptable

  N/A

• G2. TSL appropriate (refer to C4 of CoPTTM)

  Yes

  Unacceptable

  N/A

• G3. Road user flow acceptable

  Yes

  Unacceptable

  N/A

• G4. On-site Record (form must include STMS hourly checks and TSL details)

  Yes

  Unacceptable

  N/A

• G5. TMP approved?

  Yes

  Unacceptable

  N/A

• G6. Approved TMP sighted?

  Yes

  Unacceptable

  N/A

Final Result

• Score Rating

  High Standard (0-10)

  Acceptable (11-25)

  Needs Improvement (26-50)

  Unacceptable

Additional Details

• General comments/Recommendations

Completion

• Completed By : (Name & Signature)

  Sign