01/29/2021 Construction CS and TR Forms Listing

1 Pennsylvania Department of Transportation 08/07/2018 Construction Forms CS and TR Forms Listing Please note: There could be different file formats, Adobe .pdf, MS Word .doc., MS Excel .xls, MS Excel .xlt. To open a file, your computer will need the appropriate software program installed. There are different form types. Each type is indicated under the form number on the form: Fillable Fields/Print Fields can be filled in and the form printed but cannot be saved. Fillable Fields/Save As Fields can be filled in and saved as another filename. Reproduce Locally - Print and make copies as needed. Fill in by hand. Directions: 1. Click on the link of the desired form to open it.

2 2. Save a copy of the file to your hard drive. 3. Use the form from your hard drive. For information regarding Forms , please contact: Michael Lentz Bureau of Project Delivery Highway Delivery Division 400 North Street, 7th Floor West Harrisburg, PA 17120 CS-2 Construction Project - Quality Survey for Design Items CS-5 Pile Hammer Data CS-6 Pipe Installation Inspection Form CS-7 Defective Bituminous Pavement Review CS-101 Inspector s Field Office and Inspection Facilities CS-110 Payment Authorization for Material Stored or On Hand CS-111 Subcontractor/Supplier Request for Estimate Monitoring CS-200 Source of Supply Materials CS-201 Source of Supply Traffic Items CS-351F PennDOT/NECEPT Bituminous Field Technician in Training Evaluation and Sign-Off CS-351P PennDOT/NECEPT Bituminous Plant Technician in Training Evaluation and Sign-Off CS-409 Minimum Quality control Plan for Field Bituminous Paving Operation CS-430

3 Notification of Inspection CS-431 Structural Material Transfer CS-536TT Concrete Field Technician-in-Training Evaluation CS-600 Post Installation Pipe Inspection Report CS-601 Post Installation 100 Year Design Life Pipe Inspection Report CS-616 Request for Plant Material Substitution CS-704 Minimum Quality control Plan For Field Placement Concrete Operations CS-705 Electronic Changes Form CS-901 Work Zone Traffic control Compliance Checklist and Notification CS-1005 Pile Driving Log CS-1042 Minimum Quality control Plan For Field Placement of Wearing Latex Modified Mortar or Concrete Wearing Surface CS-2121 Record of Contractor s Payroll Submissions CS-4136 Punchlist Form CS-4137 Final Inspection Form CS-4138 Acceptance Certificate CS-4170 Product Evaluation Certificate of Eligibility CS-4171 Certificate of Compliance CS-4171B Certificate of Compliance for Daily Bituminous Mixtures CS-4171C Supplemental Cert for epoxy Coated or Galvanized Reinforcement - coating Facility CS-4171F Supplemental Cert for epoxy Coated or Galvanized Reinforcement - Fabricating Facility CS-4171LA Certificate of Compliance for Locally Approved Non-Bulletin Materials CS-4211A Material Test Results CS-4211B Project Summary CS-4211C Scale Check PTM 410 CS-4211E MTD Sample Submission Record CS-4211F Compression Tests CS-4211I Material Test Results Aggregate No.

4 57 CS-4211J Material Test Results Aggregate No. 8 CS-4211K Material Test Results Fine Aggregate CS-4211L Material Test Results Aggregate No. OGS CS-4211M Material Test Results Aggregate No. 67 CS-4211N Material Test Results Aggregate No. 2A CS-4220 Batcher-Mixer Slip CS-4220A Batcher-Mixer Slip (Concrete Mobile) CS-4221A Moisture Tests CS-4221C Record of Daily Orders and Releases CS-4221E Equipment Calibration Record CS-4221G Anti Skid Summary and Moisture Record CS-4225A Ground Rod Test CS-4225B Conductor Insulation Resistance Test CS-4225C Circuit Performance Test CS-4225D Highway Illumination Test CS-4225E Sign Illumination Test CS-4225F High Mast Lighting Test CS-4225G Conventional Lighting Poles static Load Test CS-4225H Highway Lighting In-Service Guarantee Notification CS-4300 Contractor Prequalification Forms (This links to the ECMS II home page.)

5 Sign in then select Business Partner then Contractors) CS-4307 Contractor s Past Performance Report CS-4307 Sub Contractor s Past Performance Report CS-4311 Status of Contracts on Hand CS-4337 Annual Inspection of Transit Truck Mixers CS-4337A Producer s Transit Truck-Mixers CS-4339R Request for Subcontractor Approval CS-4342 Field Calibration Sheet for Latex Mobile Mixers CS-4345 Borrow and/or Waste Agreement CS-4347 Force Account Daily Sign-Off CS-4347AA Final Summary (Projects Let on or After August 25, 2016) CS-4347AA Final Summary (Projects Let Prior August 25, 2016) CS-4347AS Subcontractor Summary CS-4347BA Material Breakdown CS-4347CA Labor Breakdown CS-4347 CERT Liability Insurance Rate Certification CS-4347CJ Force Account Estimate Negotiated Price Cost Justification CS-4347 CON Consumables Breakdown CS-4347D Daily Labor Breakdown CS-4347 EER Estimated Effective Rate Computation CS-4347F Daily Equipment Breakdown CS-4347 LABOR Labor Three-Part Form CS-4347MA Force Account Material Affidavit CS-4347 OED Owned Equipment Breakdown - Daily CS-4347 OEH Owned Equipment Breakdown - Hourly CS-4347 OEN Owned Equipment Breakdown No Blue Book Listing CS-4347 RES Rented Equipment and Service by Others Breakdown CS-4347 SFA

6 Force Account Salaried Foreman Affidavit CS-4347 WCI Workers Compensation Insurance 5 Year Average Rate Computation CS-4350A Work Order "Explanations" Form - Additional Work/Extra Work Category CS-4350B Work Order "Explanations" Form - Administrative Category CS-4350C Work Order "Explanations" Form - Legal Category CS-4350D Work Order "Explanations" Form - Value Engineering Category CS-4401 Curb Ramp Inspection Form CS-6105 Weigh Team Record FHWA-1446B Final Acceptance Report FHWA-1494 Semiannual Labor Compliance Enforcement Report FHWA-1365 Record of Authorization to Proceed with Major Contract Revision TR-50 Production Joint Welding Procedure Specification ( ) TR-51 Aluminum Production Joint Welding Procedure Specification ( ) TR-52 Production Joint Welding Procedure Specification ( ) TR-53 Fillet Weld Soundness Test (FWST) Results (AWS ) TR-54 Aluminum Weld Procedure Qualification Record ( ) TR-55 Procedure Qualification Record ( )

7 TR-448A Job Mix Formula Report TR-455 Disposition of Failed Materials TR-478A Report on Compaction Density Non-Movement TR-483 Micro-Surfacing Mix Design and Materials Analysis TR-498 Bituminous Concrete Plant Inspection Report TR-4109 Portland Cement Concrete Plant Report TR-4221A Concrete Mix Design Form TR-4238A District s Letter of Project Material Certification TR-4276A Report on Compaction Density by Nuclear Method TR-4276B control Strip Density by Nuclear Method TR-7011 Cement Mill Test Results TR-800 Structural Materials Quality Comment Sheet