Project Summary Information
For Federal Project Approval/Authorization
(Revised January 2011)

To:  Federal Aid Coordination Section   	Date:      
From:	Initiating Unit:      

Project Manager:      	Phone:      

Note:    Please complete this form fully. Forms that are incomplete will be returned therefore delaying project action requested. A location map (8 ½ x 11) should be provided with starting and ending project limits designated.
Project Limits: (provide full description of project limits including municipality(s) and county(s):

	Route(s):      	Section(s):      

Description
     	

Mileposts:        to       	Project Length:       miles
Mileposts:        to       	Project Length:       miles

Requested Phase of Work (Check One):
	Concept Development
	Preliminary Engineering
	Final Design
	Right of Way
	Utility PE/Reconnaissance
	Utility Relocation
	Construction (PS&E)
	Other: 

Functional System (Check One)
	Freeways & Expressways
	Other Principal Arterial
	Minor Arterial
	Major Collector
	Minor Collector
	Local
	No Functional Class

Federal Aid System (Check One)
	Interstate
	NHS Non Interstate
	Other Federal Aid Highway
	Not on any Federal Aid System

Project Oversight (Check One)
	State Administered (formally “Exempt”)
	Full Oversight (NHS)
	Full Oversight (Non NHS)
	Other

Environmental Clearance (Check One)
	1 = EIS
	2 = Categorical Exclusion
		A = Programmatic
		B = State Documented
		C = FHWA Documented
	3 = Environmental Assessment
	4 = Finding Of No Significant Impact
	5 = To Be Determined
Bridge Data:
Any projects that involve bridge replacement or bridge rehabilitation within the projects limits must have the following information supplied.

Structure Name	Structure Number	Improvement Type (*)	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
(Attach additional sheets if needed)

(*) Improvement Types
09 = New Structure
10 = Bridge Replacement-Added Capacity
11 = Bridge Replacement-No Added Capacity
13 = Bridge Rehabilitation-Added Capacity
14 = Bridge Rehabilitation-No Added Capacity

Funding Summary

Consultant (1)	     	
State Forces (2)	     	
Total Cost	     	
Federal Share	     	
State Cost	     	
Other Costs	     	
Nonparticipating	     	

Notes:
(1.) Provide Consultant Proposal/Scope of Work.
(2.) Provide State Forces Breakout by Unit and Scope.

Authorizations Checklist

Yes	Design Authorizations
	Was Consultant Proposal submitted?
	Was State Forces Breakout by unit and scope provide
	Was approved Environmental Document/Environmental Re-evaluation provided if this is Final Design request?
	Was Concept Development Report approved by FHWA if this is a Preliminary Engineering request?

Right Of Way Authorizations
	Was Firm and Sound letter submitted?
	Was Summary of Costs and Estimates provided?
	Were RW plans submitted?
	Was “approved” Environmental Document provided?

Utility Relocation Authorization
	Were Proposed Utility Agreement Modifications and Executed
	Were Utility Engineering and Construction Agreements provided?
	Was Right of Way clearance letter provided?
	Was approved Environmental Document provided?

Construction Authorizations
Were the following documents included?
	RW Certificate?
	Utility Certificate?
	Design Certificate?
	QA Certificate?
	Approved Environmental Document & Commitments Checklist?
	Engineers Estimate?
	Plans and Specifications?
	Can federal acceptance of the related PE project be requested?

	Has a Request For A New Job Number form been submitted?