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Local Assistance Program Guidelines Exhibit 9-A Application Form for HSIP Funds EXHIBIT 9-A APPLICATION FOR HIGHWAY SAFETY IMPROVEMENT PROGRAM (HSIP) FUNDS Applicants seeking Highway Safety Improvement Program (HSIP) funds must use this form. Failure to provide information that is required, or failure to prepare the application in accordance with general formatting instructions may result in your application being disqualified. See Exhibit 9-B “Application Form Instructions for HSIP Funds” for assistance in completing this form. This entire Application Form must be submitted. Applicants should download the Application Form from the Division of Local Assistance HSIP web site at: www.dot.ca.gov/hq/LocalPrograms/hsip.htm. Limit the application to eight (8) pages plus attachments. Do not provide brochures and samples of materials unless they are directly related to a response. Agency: Date: Total number of applications being submitted by your agency: Rank of this project (Note: Each project application must have a different rank): Name of Contact Person: Telephone: E-mail: Mailing Address: Street: City: Zip: County: Caltrans District: MPO: Project Location: Description of Proposed Improvement(s): Does proposed improvement(s) include Intelligent Transportation System components as defined in Chapter 12.6, Intelligent Transportation Systems, of the LAPG? ___________YES _________NO LPP 07-07 Page 9-11 November 29, 2007 Exhibit 9-A Application Form for HSIP Funds Local Assistance Program Guidelines Type of Improvement (See Exhibit 9-B: Application Form Instructions for HSIP Funds): *(Item 1 to 20: Select from the first box; Item 21 to 34: Select from the second box. Select one only.) Intersection or Road Section (Select one. If it is a road section, indicate section length.): Intersection Section Length (Miles): Road Section Speed Limit (mph): Number of Lanes: Functional Classification (select one): Visit http://web1.dot.ca.gov/hq/hpms/Page1.php to verify the functional classification. Average Daily Traffic (ADT) (Current, all directions) (required for Safety Index Project): Traffic Collision Information (required for Safety Index Project): *If “1. Roadway Illumination (where no lighting exists)” is selected as Type of Improvement, enter only night-time collisions. Time Period Collision Type to Fatal Injury Property Damage Only (PDO) Number of Collisions (NOT Number of Victims) Page 9-12 November 29, 2007 LPP 07-07 Local Assistance Program Guidelines Exhibit 9-A Application Form for HSIP Funds Project Cost Estimate Complete the following “Project Costs Estimate” section. Include only those costs that are being requested for this project. For the three (3) primary headings, identify the Federal Fiscal Year in which funds should be programmed. PROJECT COST ESTIMATE: (REQUIRED) Federal Fiscal Year Preliminary Engineering Environmental …………………………………….. $________ PS&E ……………………………………………… $________ Right of Way Engineering ……………………………………….. Acquisition ………………………………………... $________ $________ Construction Construction Engineering ……………..................... $________ Construction ………………………….......... $________ Subtotal …………………………………….. $________ Contingency (10% of Subtotal; max) …... Total Project Cost …………………………... $________ $________ Federal Funds Requested …………………... $________ The following parts of this Application Form request specific project-related information. Sections 1 and 2 request the applicant to provide a detailed narrative description related to a specific topic. If pictures, maps, exhibits, data, diagrams, etc., are submitted in response to questions or statements in the application, they must be attached to the application. 1. IDENTIFICATION AND DEMONSTRATION OF NEED This section requires the applicant to demonstrate the need for the project. Using the following questions and statements as a guide, provide a detailed narrative description of the problem. Provide some background information about the problem. How was the problem identified? How long has the problem existed? Describe the primary cause(s) of the collisions that have occurred at the location. Given that other problems may exist within the applicant’s jurisdiction, explain why this problem was chosen for improvement. Use whatever collision data, traffic data, community surveys, reports, plans, and other environmental conditions that may apply. Describe the urgency of project and the agency’s commitment to deliver project regardless of HSIP funds. If available, provide photographs to illustrate the problem or deficiency. Include these photographs as attachments. LPP 07-07 Page 9-13 November 29, 2007 Exhibit 9-A Application Form for HSIP Funds 2. Local Assistance Program Guidelines POTENTIAL FOR PROPOSED IMPROVEMENT TO CORRECT OR IMPROVE THE PROBLEM This section requires the applicant to describe how the proposed solution will improve the safety of the public. The applicant must clearly demonstrate the connection between the problem and the proposed solution. Describe how the proposed project corrects, or improves the traffic safety at or near the project site. Describe options, or alternatives that were considered. 3. IMPLEMENTATION SCHEDULE Applicants must estimate dates for the following milestones: Request Authorization to Proceed with Preliminary Engineering ……… Obtain Environmental Clearance (NEPA) ……………………………… Request Authorization to Proceed with Right of Way (if applicable) ….. Obtain Right of Way Clearance ………………………………………… Request Authorization to Proceed with Construction …………………... Complete Construction of Project ………………………………………. 4. PROJECT SITE IS A LISTED LOCATION IN THE CURRENT CALIFORNIA FIVE PERCENT (5%) REPORT ________Yes, __________________LOCATION IDENTIFICATION NUMBER (See Five Percent (5%) Report, Appendix B) For web site access to the Five Percent (5%) Report, go to: http://safety.fhwa.dot.gov/fivepercent/index.htm or contact your District Local Assistance Engineer for assistance. Page 9-14 November 29, 2007 LPP 07-07 Local Assistance Program Guidelines 5. Exhibit 9-A Application Form for HSIP Funds APPLICATION SIGNATURES An agency official representing the applicant must sign the application. The undersigned affirms that the statements contained in the application package are true and complete to the best of the applicant’s knowledge. The undersigned also affirms that the applicant's agency owns, operates and maintains the facility upon which the proposed improvements will be constructed. If portions of the improvements extend into areas where the applicant has no jurisdictional authority, a notation must be made that officials representing the affected local agencies support the project. In the notation, provide names and telephone numbers of whom to contact for corroboration. Only one agency official needs to sign the application. “Agency Official” means Director, Assistant Director, Executive Director, Assistant Executive Director, or their respective designated administrators, engineers, or planners. Agency Official: _____ (Name) _____________ Signature _______________ Date Title: Phone Number: E-mail: (If available) Notation: (If applicable) Distribution: Original and two copies – DLAE LPP 07-07 Page 9-15 November 29, 2007 Exhibit 9-A Application Form for HSIP Funds Page 9-16 November 29, 2007 Local Assistance Program Guidelines LPP 07-07 Local Assistance Program Guidelines Exhibit 9-B Application Form Instructions for HSIP Funds EXHIBIT 9-B APPLICATION FORM INSTRUCTIONS FOR HSIP FUNDS Applicants should submit the original application and two copies to the respective Caltrans District Offices, directed to the attention of the District Local Assistance Engineer (DLAE), by the designated deadline. Download the Application Form from the Division of Local Assistance HSIP web site at: www.dot.ca.gov/hq/LocalPrograms/hsip.htm.Limit the application to eight (8) pages plus attachments. Do not provide brochures and samples of materials unless they are directly related to a response. Any maps, schematics, drawings, figures and/or photographs attached to the application should be made on 8-1/2 x 11-inch paper. For projects that involve multiple locations, a separate form must be submitted for each spot location. For projects that involve roadway segments that exceed 1 mile in length, a single application may be submitted if the Average Daily Traffic (ADT) throughout the project's limits does not vary by more than 20%. The application form contains the following fields: Agency: Provide the name of your agency. Date: Indicate the Application Date. Total number of applications being submitted by your agency: Provide the total number of applications being submitted by your agency for HSIP Funds, including this application. Rank of this project: Rank of this project among all the applications submitted by your agency. “1” means the highest priority. Each project application must have a different rank. Name of Contact Person: Name of the contact person for this application. Telephone: Telephone number of the contact person. E-mail: E-mail address of the contact person. Mailing Address: Mailing address of the contact person for this application. County: Name of the County where the proposed project will be constructed. Caltrans District: From the drop-down list, select the Caltrans District (1 to 12) where the proposed project will be constructed. MPO: From the drop-down list, select the MPO (Metropolitan Planning Organization) that will be involved with the programming of the project in the FTIP. Select “Other” if not applicable. The following 18 MPOs are available from the drop-down list: AMBAG: Association of Monterey Bay Area Governments BCAG: Butte County Association of Governments COFCG: Council of Fresno County Governments KCAG: Kings County Association of Governments KCOG: Kern Council of Governments MCAG: Merced County Association of Governments MCTC: Madera County Transportation Commission MTC: Metropolitan Transportation Commission SACOG: Sacramento Area Council of Governments SANDAG: San Diego Association of Governments SJCOG: San Joaquin Council of Governments SLOCOG: San Luis Obispo Council of Governments SBCAG: Santa Barbara County Area of Governments SCRTPA: Shasta County Regional Transportation Planning Agency SCAG: Southern California Association of Governments LPP 07-07 Page 9-17 November 29, 2007 Exhibit 9-B Application Form Instructions for HSIP Funds Local Assistance Program Guidelines STANCOG: Stanislaus Council of Governments TCAG: Tulare County Association of Governments TMPO: Tahoe Metropolitan Planning Organization Project Location: Provide road name and/or geographical references to project location. Description of Proposed Improvement(s): Describe the proposed improvements. Intelligent Transportation Systems Component: Answer “yes” or “no.” If the reply is “yes,” Chapter 12.6 of the LAPG shall be followed. Type of Improvement: Proposed type of improvement. Select one (and only one) from the predefined list (see below). Type of Improvements 1. Roadway Illumination (where no lighting exists) 2. Relocation or Breakaway Utility Poles 3. Traffic Signs (General) 4. Curve Warning Arrows 5. Advance Curve Warning with Advisory Speed 6. 4-Way Stop 7. Upgrade with Breakaway Supports 8. Upgrade Median Barrier (includes new median barrier) 9. Remove Obstacles 10. New Traffic Signals 11. Upgrade Guardrail (include new guardrail) 12. Impact Attenuators 13. Upgrade Traffic Signals (includes interconnection) 14. Sight Distance Improvement 15. Construct Raised Median for Traffic Separation 16. Groove Pavement for Skid Treatment 17. Turning Lanes (except for new left-turn lane) and Traffic Channelization 18. New left-turn lane at signalized intersection (with no left-turn phase) 19. New left-turn lane at signalized intersection (with left-turn phase) 20. New left-turn lane at nonsignalized intersection 21. Two-way left-turn lane 22. Pavement Markings and Delineation 23. Widen or Improve Shoulder 24. Flatten Side Slopes 25. Realign Roadway 26. Overlay for Skid Treatment 27. Reconstruction (combinations & miscellaneous) 28. Emergency Vehicle Priority Systems 29. Bicycle/Pedestrian Improvements 30. Public Transportation Facility 31. Traffic Calming 32. Red Light Running Detection System 33 In-pavement Crosswalk Lights 34. Other Item 28, 29, 30, 31, 32 and 33 are eligible improvements for Work Type projects, but not for Safety Index projects. Intersection or Road Section: Check the appropriate description. If it is for a road section, indicate the length of the road section in miles. Page 9-18 November 29, 2007 LPP 07-07 Local Assistance Program Guidelines Exhibit 9-B Application Form Instructions for HSIP Funds Speed Limit (mph): Indicate the speed limit. Number of Lanes: Indicate the total number of travel lanes of the road (both directions). Do not include left-turn lanes, right-turn lanes or two-way turn lanes. If it is an intersection, use the average number of lanes of the roads approaching the intersection. For example, if 2 approaches have 2 lanes each, and 2 other approaches have 1 lane each, the average number of lanes is 1.5. Functional Classification: Select one from the following twelve categories: 01-Rural Principal Arterial Interstate 02-Rural Other Principal Arterial 06-Rural Minor Arterial 07-Rural Major Collector 08-Rural Minor Collector 09-Rural Local 11-Urban Principal Arterial Interstate 12-Urban Principal Arterial - Other Fwys or Expwys 14-Urban Other Principal Arterial 16-Urban Minor Arterial 17- Urban Collector 19- Urban Local Visit http://web1.dot.ca.gov/hq/hpms/Page1.php to verify the functional classification. Average Daily Traffic (ADT): Indicate the existing (or most current) ADT volume of the proposed location. The ADT is required to qualify as a Safety Index project. If the proposed improvement is at an intersection, add the existing (or most current) ADT volumes approaching the intersection from all directions. The ADT is the combined traffic volume of all approaches to the intersection on an average day. If the proposed improvement is not at an intersection, the ADT is the number of vehicles that use the section of roadway proposed for improvement in both directions on an average day. Traffic Collision Information: The information to be provided in the table is required to qualify as a Safety Index project. Do not include unreported collisions since the evaluation formula has already been adjusted to account for this anomaly. Collision summary reports that corroborate the values must be attached to the application. Do not attach the law enforcement collision reports. For spot improvements, collisions that occurred within 1/10 mile may be included. For corridor or linear improvements, collisions that occurred within the corridor plus collisions that occurred within 1/10 mile of the ends of the project limits may be included. For intersection improvements, collisions that occurred within 300 feet of the intersection in all directions may be used. If the distance to the nearest intersection is less than 600 feet, only those collisions that occurred from midblock may be used. If “1. Roadway Illumination (where no lighting exists)” is selected as Type of Improvement, enter only night-time collisions. LPP 07-07 Page 9-19 November 29, 2007 Exhibit 9-B Application Form Instructions for HSIP Funds Local Assistance Program Guidelines Time Period: The time period of the collision data provided. Data should be provided for at least the last three years. Number of Collisions: The number of the collision occurrences (not number of victims) in the time period per three severities: Fatal, Injury and Property Damage Only (PDO). Project Cost Estimate: See the Application Form. Identification and Demonstration of Need: See the Application Form. Potential for Proposed Improvement to Correct or Improve the Problem: See the Application Form. Implementation Schedule: Estimated dates of the project implementation milestones. Project Site is a Listed Location in the Current California Five Percent (5%) Report: See the Application Form. Application Signatures: See the Application Form. Page 9-20 November 29, 2007 LPP 07-07 Local Assistance Program Guidelines Exhibit 9-C Project Status Report EXHIBIT 9-C PROJECT STATUS REPORT PROJECT STATUS REPORT Due July 1 each year (Required only if a Construction Contract has not been awarded by July 1) Agency:______________________________________________ Date:_____________________________ Project Number: (to be completed by Caltrans District) Project Location: ________________________________________________________________________ ________________________________________________________________________________________ Work Description: _______________________________________________________________________ ________________________________________________________________________________________ ______________________________________________________________________________________________ __________________________________________________________________________________ Original Project Award Date: ________________________________________ Current Project Award Date: ________________________________________ If “current project award date” is not within the same federal fiscal year as the “original projected award date,” attach letter requesting time extension. Original Cost Estimate: _____________________________________________ Current Cost Estimate: ______________________________________________ Reason for Difference (increase or decrease): __________________________________________________ ______________________________________________________________________________________________ __________________________________________________________________________________ Other Comments:____________________________________________________________________________________ ______________________________________________________________________________________________ ____________________________________________________________________________ Prepared by:________________________________ E-mail:_____________________________________ Telephone:__________________________________ LPP 07-07 Page 9-21 November 29, 2007 Exhibit 9-C Local Assistance Program Guidelines Project Status Report Page 9-22 November 29, 2007 LPP 07-07