This form is only to be used when there are multiple Volume/Speed/Class Data Request Form locations for the same North Carolina Department of Transportation – Transportation Mobility and Safety Division project and WBS/billing code. Data Parameters: Duration: 48 hours (standard) Increment: 1 hour (standard) Begin Day: Time: End Day: Time: Video as part of Submittal: No (indicate specific beginning and ending dates and times only if needed)

Turnaround Time: 2 Weeks (standard) Schools in session? Yes Comments:

Standard speed bins are 0-9.99, 10-14.99, 15-19.99, 20-24.99, 25-29.99, 30-34.99, 35-39.99, 40-44.99, 45-49.99, 50-54.99, 55-59.99, 60-64.99, 65-69.99, 70-74.99, and 75+. Indicate different ones, if needed:

Classification bins are according to the FHWA Thirteen (13) Class Scheme.

Justification Reason: (select from list) Purpose: (select from list)

Billing Project: WBS (or other billing code): Function Code: Location/Route Tier: (select)

Requestor Name: Organization: Phone: Email:

Signature: ______Date: ______

Approvals Name: ______Title: ______

Signature: ______Date: ______

Signature: ______Date: ______(State Traffic Safety Engineer, if needed)

Revised: March 24, 2014 This form is only to be used when there are multiple Volume/Speed/Class Data Request Form locations for the same North Carolina Department of Transportation – Transportation Mobility and Safety Division project and WBS/billing code. Locations – Attach a separate map for each location with the location number clearly indicated # Div. County City Sig. Inv. # RR Xing # Bridge # Sta.# AADT Speed Limit Work Zone? No 1 Description: No 2 Description: No 3 Description: No 4 Description: No 5 Description: No 6 Description: No 7 Description: No 8 Description: No 9 Description: No 10 Description: No 11 Description: No 12 Description: No 13 Description: No 14 Description: No 15 Description: * AADT – Sum of all approaches divided by 2. # Div. County City Sig. Inv. # RR Xing # Bridge # Sta.# AADT Speed Limit Work Zone? 16 No

Revised: March 24, 2014 This form is only to be used when there are multiple Volume/Speed/Class Data Request Form locations for the same North Carolina Department of Transportation – Transportation Mobility and Safety Division project and WBS/billing code. Description: No 17 Description: No 18 Description: No 19 Description: No 20 Description: No 21 Description: No 22 Description: No 23 Description: No 24 Description: No 25 Description: No 26 Description: No 27 Description: No 28 Description: No 29 Description: No 30 Description: * AADT – Sum of all approaches divided by 2.

Revised: March 24, 2014 This form is only to be used when there are multiple Volume/Speed/Class Data Request Form locations for the same North Carolina Department of Transportation – Transportation Mobility and Safety Division project and WBS/billing code.

Office Use Only – Processing Sheet:

Location Number (1-30): ______

Division (1-14): ______

Contractor Assignment: ______

Count Number: ______

Cost: $______

Date Sent: ______

Due Date: ______

Processed By: ______

Revised: March 24, 2014