Form FHWA R-13 FHWA R-13 Excellence in Right-of-Way Awards Program Nomination For

This collection of information is voluntary and will be used to accept nominations for the collection for FHWA’s Excellence in Right-of-Way Awards Program and Utility Relocation and Accommodation Awards Program Public reporting burden is estimated to average 6 hours per response, including the time for reviewing instructions searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is 2125-XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Michael Howell Information Collection Clearance Officer, Federal Highway Administration, 1200 New Jersey Avenue, SE, Washington, DC 20590.

Excellence in Utility Relocation and Accommodation Awards Nomination Form

Nominations will be accepted through January 31, 2014 and must be submitted electronically to: FHWAHEPR@dot.gov. Nominations should include this form, a written endorsement by a State Department of Transportation, and at least one photo. All photos must have a minimum 300 dpi and have a file format of .jpg or .gif. These photos become property of FHWA. Nominations made after January 31, 2014 will not be considered.

For more information or questions, please email: FHWAHEPR@dot.gov

(*indicates required information)

1. Nominator’s Business Contact Information:
Title*			First Name*			Last Name*
     			     			     
Company/Organization Name:*			     
Mailing Address:*			     
City*			State*			Zipcode*
     			    			     
Phone:*			     
Fax:			     
Email:*			     
Comments: (500 characters maximum)			     
2. Nomination Category (Select one with 'X' in box):
Project Development		Construction Management			Innovation
Incentives for Utility Relocation		Utility Program Performance

For nominations related to the Program Development, Construction Management, Innovation, and Incentives Relocation categories, please complete Sections 3, 4, and 7 below. For nominations related to the Utility Program Performance category, please complete Sections 5, 6, and 7 below.

3. Project Information (For Project Development, Construction Management, Innovation, and Incentives for Utility Relocation categories):
Individual/Team Leader:*
Title*	First Name*	Last Name*
     	     	     
Company/Organization Name:*	     
Mailing Address:*	     
City*	State*	Zipcode*
     	     	     
Phone:*	     
Fax:	     
Email:*	     
Team Members (no more than three individuals)	     
	     
	     
Project Owner*	     
Principal Designer*	     
Principal Contractor (not applicable for “Project Development” category)*	     
Location*	City*	State*
     	     	     
County*	Local Name (if appropriate)	Date Project Completed*
     	     	     

4. Project Information Continued (For Project Development, Construction Management, Innovation, and Incentives for Utility Relocation categories):
Describe the project scope with particular detail to the utility-related project features and other unique aspects of the project; specifically address the criteria established for the nominated category. (Note that for the “Innovation” category, the description should focus on the technology, process or practice that supported the project or utility program)* (3,000 characters maximum)	     
Based on the above description, provide a brief synopsis of the project to be used for official award publication notices. (500 characters maximum)	     

5. Individual or Team Information (For Utility Program Performance Category):
Title*	First Name*	Last Name*
     	     	     
Company/Organization Name:*	     
Mailing Address:*
City*	State*	Zipcode*
     	     	     
Phone:*	     
Fax:	     
Email:*	     
Team Members (no more than two additional individuals)
Title*	First Name*	Last Name*
     	     	     
Mailing Address:*
City*	State*	Zipcode*
     	     	     
Phone:*	     
Fax:	     
Email:*	     
Title*	First Name*	Last Name*
     	     	     
Mailing Address:*
City*	State*	Zipcode*
     	     	     
Phone:*	     
Fax:	     
Email:*	     
Comments: (500 characters maximum)	     

6. Individual or Team Information (For Utility Program Performance Category):
Describe how the achievements of the nominated individual have successfully addressed the criteria established for the award category:* (3,000 characters maximum)	     
Based on the above description, provide a brief synopsis of the nominee(s) to be used for official award publication notices. (500 characters maximum)	     
7. Upload Photos:
Please submit up to 3 photos with this form and include file names and brief photo descriptions below.
Photo File Name	Photo Description
1.      	     
2.      	     
3.