DATE:

PROJECT INFORMATION:

PJN:

Project Name (C-R-S):

PID:

Begin (MM/Cross Street):

Est. Completion Date:

End (MM/Cross Street):

REGIONAL, COUNTY OR LOCAL 911 DISPATCH:

Dispatch Center

Name, if applicable

Primary Contact Number

Alternate Contact Number

FIRE:

Agency

Name, if applicable

Primary Contact Number

Alternate Contact Number

EMS:

Provider

Name, if applicable

Primary Contact Number

Alternate Contact Number

POLICE/PATROL:

Agency

Name, if applicable

Primary Contact Number

Alternate Contact Number

ODOT CONTACTS:

Title/Role

Name

Primary Contact Number

Alternate Contact Number

Project Engineer

TSMO Coordinator

Dist. WZ Traffic Manager

Dist. Safety Consultant

Public Involvement Officer

County Manager

Traffic Management Center

Special Hauling Permits

CONTRACTOR TIM CONTACTS:

Title

Name

Primary Contact Number

Alternate Contact Number

Superintendent

WTS

OTHER:

Primary Contact Number

Alternate Contact Number

Route Covered by Freeway Service Patrol (FSP):

Yes

No