Form 1627 "Local Agency Programs Safety Project Submittal Form" - Michigan

What Is Form 1627?

This is a legal form that was released by the Michigan Department of Transportation - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the Michigan Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form 1627 by clicking the link below or browse more documents and templates provided by the Michigan Department of Transportation.

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Download Form 1627 "Local Agency Programs Safety Project Submittal Form" - Michigan

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LOCAL AGENCY PROGRAMS SAFETY PROJECT
Michigan Department
Clear Form
Of Transportation
SUBMITTAL FORM
1627 (05/16)
FUNDING TEMPLATE:
FISCAL YEAR:
LOCAL AGENCY
LOCAL AGENCY CONTACT
PHONE NO.
FAX NO.
EMAIL ADDRESS
ALTERNATIVE CONTACT
PHONE NO.
FAX NO.
EMAIL ADDRESS
HOUSE DISTRICT
SENATE DISTRICT
PROPOSED PROJECT LOCATION, LIMITS AND PROJECT DESCRIPTION
PROPOSED COST
TIME OF RETURN (YEARS)
IMPROVEMENT CATEGORY (CHECK ALL CATEGORIES THAT APPLY)
Local Road Safety Plan Emphasis Area
BENEFIT TO COST RATIO
TOWNSHIP/CITY
Intersection Improvements
Roadway and Structure Improvements
PLEASE LIST THE CRASH REDUCTION FACTORS USED:
Roadside Improvements
DOES A PROJECT IMPACT A SCHOOL OR OTHER SENSITIVE
Pedestrian and Bicycle Improvements
ORGANIZATION? PLEASE DESCRIBE:
Systemic (Explanation of how improvement will improve safety
and reduce crashes is required below.)
Other ________________________________________
ROADWAY DATA
CROSS ROAD DATA (If an intersection improvement)
PRIMARY ROUTE NAME
ROUTE NAME
ADT
ADT
PERCENT COMMERCIAL
*NO. OF CRASHES
PERCENT COMMERCIAL
*NO. OF CRASHES
* NO. OF FATAL CRASHES
*NO. OF “A” TYPE CRASHES
*NO. OF FATAL CRASHES
*NO. OF “A” TYPE CRASHES
*PERIOD OF CRASH DATA
FUNCTIONAL CLASSIFICATION
*PERIOD OF CRASH DATA
FUNCTIONAL CLASSIFICATION
*Please attach Crash Summary and UD-10’s to your project submittal with the most recent 5 years of available data.
EXPLANATION OF HOW THE PROPOSED IMPROVEMENT WILL IMPROVE SAFETY AND REDUCE CRASHES
HAS YOUR LOCAL AGENCY RECEIVED APPROVAL OF A SAFETY PROJECT OR HRRR PROJECT THROUGH MDOT’S LAP UNIT IN THE PAST 5
YEARS?
YES
NO
SAFETY PROJECT
HRRR PROJECT
IF YES, HAVE ALL PROJECTS BEEN COMPLETED?
YES
NO
IF NO, PLEASE EXPLAIN WHY
OTHER PROJECT CONSIDERATIONS
LOCAL AGENCY PROGRAMS SAFETY PROJECT
Michigan Department
Clear Form
Of Transportation
SUBMITTAL FORM
1627 (05/16)
FUNDING TEMPLATE:
FISCAL YEAR:
LOCAL AGENCY
LOCAL AGENCY CONTACT
PHONE NO.
FAX NO.
EMAIL ADDRESS
ALTERNATIVE CONTACT
PHONE NO.
FAX NO.
EMAIL ADDRESS
HOUSE DISTRICT
SENATE DISTRICT
PROPOSED PROJECT LOCATION, LIMITS AND PROJECT DESCRIPTION
PROPOSED COST
TIME OF RETURN (YEARS)
IMPROVEMENT CATEGORY (CHECK ALL CATEGORIES THAT APPLY)
Local Road Safety Plan Emphasis Area
BENEFIT TO COST RATIO
TOWNSHIP/CITY
Intersection Improvements
Roadway and Structure Improvements
PLEASE LIST THE CRASH REDUCTION FACTORS USED:
Roadside Improvements
DOES A PROJECT IMPACT A SCHOOL OR OTHER SENSITIVE
Pedestrian and Bicycle Improvements
ORGANIZATION? PLEASE DESCRIBE:
Systemic (Explanation of how improvement will improve safety
and reduce crashes is required below.)
Other ________________________________________
ROADWAY DATA
CROSS ROAD DATA (If an intersection improvement)
PRIMARY ROUTE NAME
ROUTE NAME
ADT
ADT
PERCENT COMMERCIAL
*NO. OF CRASHES
PERCENT COMMERCIAL
*NO. OF CRASHES
* NO. OF FATAL CRASHES
*NO. OF “A” TYPE CRASHES
*NO. OF FATAL CRASHES
*NO. OF “A” TYPE CRASHES
*PERIOD OF CRASH DATA
FUNCTIONAL CLASSIFICATION
*PERIOD OF CRASH DATA
FUNCTIONAL CLASSIFICATION
*Please attach Crash Summary and UD-10’s to your project submittal with the most recent 5 years of available data.
EXPLANATION OF HOW THE PROPOSED IMPROVEMENT WILL IMPROVE SAFETY AND REDUCE CRASHES
HAS YOUR LOCAL AGENCY RECEIVED APPROVAL OF A SAFETY PROJECT OR HRRR PROJECT THROUGH MDOT’S LAP UNIT IN THE PAST 5
YEARS?
YES
NO
SAFETY PROJECT
HRRR PROJECT
IF YES, HAVE ALL PROJECTS BEEN COMPLETED?
YES
NO
IF NO, PLEASE EXPLAIN WHY
OTHER PROJECT CONSIDERATIONS