Project Engineer:
Designer:
Key Route: / Section: / County:
Functional Classification: / Marked Route/Road Name:
Termini:
Project Length: / Net Length:
Contract No.: / Program Estimated Cost:
State Job No.: / PPS No.:
Fund Year: / Fund Type:
CRS: / From Mile Sta.: / To Mile Sta.: / Distresses:
CRS: / From Mile Sta.: / To Mile Sta.: / Distresses:
CRS: / From Mile Sta.: / To Mile Sta.: / Distresses:
For Marked Routes, 5.5≤CRS≤6.5 / Yes / No / For Unmarked Routes, 4.5≤CRS≤6.0 / Yes / No
Total ADT/Year: / MU ADT:
No. of Five Percent Report (FPR)Locations(BDE Manual Sec. 12-3.08(b)):
Total Cost Estimate: / Cost/mile: / FPR Location Cost:
Total Cost of Items 4a-4e(see below): / Less than 15% of Total Cost Estimate? / Yes / No
Existing Roadway Width: / Exist. Median Type & Width: / No. of Through Lanes:
Existing Traveled Way Width: / Existing Pavement Type:
Existing Paved Shoulder Type: / Existing Paved Shoulder Width: / Aggregate Shoulder Width:
Proposed Resurfacing Thickness: / Exception to Policy: / Yes / No
If yes, attach a copy of the Bureau of Design and Environment’s approval.
Percent Patching Proposed: / %
If MU ADT is less than 250, is patching ≤ 6%: / Yes / No
If MU ADT is 250 or greater, is patching ≤ 5%: / Yes / No
Answer the following items YES or NO or fill in blanks. If marked YES, an attachment may be necessary to explain the answer.
Yes / No
1a. / Is the improvement on the National Highway System (NHS)?
1b. / Is the highway a designated truck route? If yes, designation class:
2a. / Is a local agency involved with the project? If yes, name of the agency.
2b. / Is the agency notified? Is agreement signed / pending?
3. / Are any design exceptions other than resurfacing thickness required? (Attach minutes of coordination meeting)
4a. / Are spot guardrail updates or repairs proposed?
4b. / Are minor spot drainage improvements including culvert extensions/repairs proposed?
4c. / Is manhole or inlet adjustment outside of the pavement proposed?
Yes / No
4d. / Is isolated ditch cleaning proposed?
4e. / Are isolated culvert end section replacements proposed?
5. / Are curb repairs proposed? Existing curb and gutter type / length of repair
6a. / Do pedestrian crosswalks, marked or unmarked, exist within the limits of resurfacing?
6b. / If yes, will the altered curb ramps be made accessible as part of this project (BDE Manual Sec. 58-1.09)?
6c. / If no, attach approved BDE 3101 ADA Statement of Maximum Extent Practicable.
7a. / Do parking lanes exist within project limits?
7b. / If yes, is local participation needed?
8. / Do drainage problems exist?
9. / Do storm sewer inlets need repair replacement?
10. / Is cold milling of existing surface proposed? Reason:
11a. / Is reflective crack control proposed?
11b. / If yes, have CRS distress requirements been reviewed?
12. / Are detector loops to traffic counters present?
13. / If FPR locations exist, can they be corrected by resurfacing or by superelevation improvements?
14. / Are geometric spot improvements proposed to correct FPR location(s)?
(If yes, attach analysis and coordination meeting minutes which discussed improvements)
15a. / Are there any existing public education facility entrances onto the route?
15b. / If yes, will the entrances be improved? ( BDE Manual Section 11-2.08(h))
16. / Is bridge resurfacing proposed? (If yes, attach BBS concurrence)
17. / Project discussed and reviewed at coordination meeting on:
18. / Other comments:
DESIGN APPROVAL AND CATEGORICAL EXCLUSION DETERMINATION
Federally Approved Categorical Exclusion
State Approved Categorical Exclusion
Federally Approved Categorical Exclusion approved by:
FHWA Representative Signature / Date
Regional design approval by:
Deputy Director of Highways/Region Engineer Signature / Date
Printed 10/12/2018Page 1 of 2BDE 2565 (Rev. 12/22/15)