Traffic Management Plan Submission Form

Details of company submitting the Traffic Management Plan

Company Name
Address
Contact Name
Email Address
Mobile Number
Phone Number / Fax Number
Signature of applicant / Date

Work Zone Details

Road sections affected by the proposed works / Road 1 / Traffic Volume (vpd)
Road 2 / Traffic Volume (vpd)
Suburb
Description of proposed works
Site supervisor
contact name / Site supervisor
contact number
Times the proposedTMP will be in operation / Start Am/Pm / Finish Am/Pm
Duration of work / Start Date / Finish Date
Weekdays / Yes / No / Weekends / Yes / No
Will the works: / Require deviation of vehicular traffic into an on-coming traffic lane? / Yes / No
Be conducted on, partly on or affect a bridge or other structure? / Yes / No
Cause significant delay (5 minutes or more) to traffic on an arterial road or municipal road? / Yes / No
How long will closure of the road or part of the road to vehicular traffic be required for?
*NOTE: An afterhours TMP plan will need to be submitted if the worksite is to remain under changed traffic conditions overnight. / A continuous period of more than 12 hours? / Yes / No
More than 24 hours in a 7 day period? / Yes / No
Type of Road Closure / None / Partial / Full
Clearance distance between work area/ workers and traffic lanes / <1.2m / 1.2-3.0m / 3.0-9.0m / >9.0m
Proposed Speed Limit Restriction
# Note: VIC Roads Memorandum of Consent is required for speed reductions below 40km/h and for use of traffic signals at worksites / None / 40km/h / 60km/h / 80km/h
Identified Site Risk Rating / Very High / High / Medium / Low
Facilities and special requirements that have been identified within or in the vicinity of the work zone that need to be addressed as part of the Traffic Management
*If works are going to impact on these items they require notification prior to works commencing / Access and/or redirection of pedestrians, cyclists and the disabled
Properties / businesses*
Schools*
Public Transport*
Garbage collection*
Checklist:
Consent to Work within Road Reserve Approval Letter
Approved functional drawing(s) attached
TMP plan(s) attached
Memorandum of Authorisation VicRoads (if applicable) attached

Submit form and plan(s) via the following methods

Email:

Fax:9743 9970

Please note: Traffic Management Plans are required to be submitted at least 10 business days prior to works commencing to ensure sufficient time to register and review the TMP and if needed request further information.

Office Use Only

Date Received
Responsible Officer
TMP Reference No.