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PRE-QUALIFICATION SCHEMETRAFFIC MANAGEMENT SERVICES GROUP

TRAFFIC CONTROL SYSTEMS INSTALLATION AND MAINTENANCE

Self-Assessment Check List

This check list is created for contractors to conduct a self-assessment on their prequalification application that they intend to submit. It is based on the requirements for individual TRAFFIC MANAGEMENT SERVICES GROUP – CONTRACT levels and covers the information given in

Part A and Part B forms. Contractor is required to fill in the relevant fields and submit this check list as part of their prequalification submission.

New Application

Review

Company Name:Contact Name:Contact Number: Email:

Levels Applying For (Only tick levels being applied for):

Metro (and Rural by default) Traffic Signals Installation (STS1) Traffic Signals Maintenance (STS2) Public Lighting and Basic Electrical works (STCE1) Other On-Road Electrical ITS Devices) (STCE2) Specialist On-Road ITS Devices (STCE3) Communications (SCTV) Vehicle Detection Loops (SVDL) Supply of On-road Electronic Devices (SOED)

Rural Only Traffic Signals Maintenance (STS2)

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APPLICATION FOR PRE-QUALIFICATION PART “A”

Company Details (VicRoads Use Only)

Australian Business Number (ABN): Australian Company Number (ACN):Business information provided: Yes No Evidence of Current Workcover Certificate Provided: Yes No Policy Number: Expiry Date:“Part A” Declaration Completed: Yes No

APPLICATION FOR PRE-QUALIFICATION PART B of 47 Rev. 2

Management Systems (VicRoads Use Only)

System Quality OH&S EMS Industrial RelationsSystem Standard ISO 9001:2016

VicRoads Check List CCF code

Safety Map Level 1.AS4801:2001AS/NZ/ISO 45001VicRoads Checklist CCF code

ISO 14001:2016VicRoads Check List CCF code

VicRoads Self-Assessment Checklist and Signed Declaration Provided

Approval Type Registered by CCF3rd Party Certification Audited to VicRoads

Registered by CCF3rd Party Certification Audited to VicRoads

Registered by CCF3rd Party Certification Audited to VicRoads

Name of Approval OrganisationApproval DateExpiry DateRegistration No.

Comments

Pre-qualification Part A and Part B (VicRoads Use Only) of 47 Rev. 2

Business Information Complies Does Not Comply Quality System Complies Does Not Comply OH&S Complies Does Not Comply EMS Complies Does Not Comply Financial Assessment – (Requested by VicRoads once all the documentation is submitted) Complies Does Not Comply

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STS1

APPLICATION FOR PRE-QUALIFICATION “PART B” (Only complete the fields that are relevant to the levels the company is applying for)

“Part B” Declaration Completed YES NO

APPLYING FOR TRAFFIC SIGNALS MAINTENANCE (STS1) METRO - YES NO (Includes Rural by default) Relevant Work Undertaken

Traffic Signals Yes No Freeway Ramp Metering Yes No Overhead Lane Control Signals Yes No Direct Driven Peripheral Elec. Signage Yes No

Specific Eligibility Criteria Complies Minimum of two permanent full time employees that are holders of an Electrician’s Licence. Such

personnel shall be based at company’s office/depot; (Evidence that the staff are permanent such as payroll summary)

Yes No

Minimum of three years relevant field experience within the last six years within this area of competency; Yes No

Minimum number of four suitable vehicles. Yes No

Comments

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STS1

PERSONNEL EXPERIENCE SUMMARYOnly provide personnel experience relevant to the levels company is applying for. The experience requirements for each level are described in Traffic Management Services (Contractor) GROUP Categories and Levels Eligibility Criteria. The criteria document can be found on VicRoads website. Note that multiple copies of this page may need to be submitted in order for company to demonstrate that nominated employees meet the minimum experience requirements specified in the Eligibility Criteria. All the relevant projects need to be listed, their description, duration as well as the company that the employee worked for at the time.

NOMINATED EMPLOYEE NAME:

PROFESSIONAL/TECHNICAL QUALIFICATION:

(ensure that copies of any licences or qualifications are provided as part of the application)

PROJECT HISTORY (EMPLOYEE)COMPANY

NAMENAME OF THE

PROJECTDURATION WORKED (start and completion date)

DETAILED DESCRIPTION OF WORKS

REFEREE CONTACT DETAIL(email and phone number)

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STS1





NAMENAME OF THE




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STS1

STS1 Personnel & Company Summary (VicRoads Use Only)Summary provided by contractor: Yes No Referees Check Conducted

Yes No Does the experience and qualifications of the employees comply with STS1 level

Yes No Checked by VicRoads OfficerYes No Does the company have the required number of vehicles Yes No

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STS2

APPLYING FOR TRAFFIC SIGNALS MAINTENANCE (STS2) METRO - YES NO (Includes Rural by default) Relevant Work Undertaken

Traffic Signals Yes No Freeway Ramp Metering Yes No Overhead Lane Control Signals Yes No Direct Driven Peripheral Elec. Signage Yes No

Specific Eligibility Criteria Complies Minimum of four permanent full time employees that are holders of an Electrician’s License Such

personnel shall be based at company’s office/depot; (Evidence that the staff are permanent such as payroll summary)

Yes No



Comments

PERSONNEL EXPERIENCE SUMMARY

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STS2

Only provide personnel experience relevant to the levels company is applying for. The experience requirements for each level are described in Traffic Management Services (Contractor) GROUP Categories and Levels Eligibility Criteria. The criteria document can be found on VicRoads website. Note that multiple copies of this page may need to be submitted in order for company to demonstrate that nominated employees meet the minimum experience requirements specified in the Eligibility Criteria. All the relevant projects need to be listed, their description, duration as well as the company that the employee worked for at the time.





NAMENAME OF THE





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STS2




NAMENAME OF THE





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STS2




NAMENAME OF THE




STS2 Metro - Personnel & Company Summary Review (VicRoads Use Only)

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STS2

Summary provided by contractor: Yes No Referees Check ConductedYes No

Does the experience and qualifications of the employees comply with STS2 level


APPLYING FOR TRAFFIC SIGNALS MAINTENANCE (STS2) RURAL - YES NO Relevant work undertaken Traffic Signals Yes No

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STS2

Direct Driven Peripheral Elec. Signage Yes No

Number of Sites Specific Eligibility Criteria Complies

Up to 100 Minimum of one permanent full time employee plus backup that are holders

of an Electrician’s License.(Evidence that the staff are permanent such as payroll summary)

Yes No

Minimum number of two suitable vehicles. Yes No

101-200 Minimum of two permanent full time employees that are holders of an

Electrician’s License.(Evidence that the staff are permanent such as payroll summary)

Yes No

Minimum number of two suitable vehicles. Yes No over 200 Minimum of four permanent full time employees that are holders of an

Electrician’s License.(Evidence that the staff are permanent such as payroll summary)

Yes No


Comments

PERSONNEL EXPERIENCE SUMMARYOnly provide personnel experience relevant to the levels company is applying for. The experience requirements for each level are described in Traffic Management Services (Contractor) GROUP Categories and Levels Eligibility Criteria. The criteria document can be found on VicRoads website.

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STS2

Note that multiple copies of this page may need to be submitted in order for company to demonstrate that nominated employees meet the minimum experience requirements specified in the Eligibility Criteria. All the relevant projects need to be listed, their description, duration as well as the company that the employee worked for at the time.





NAMENAME OF THE







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STS2


NAMENAME OF THE




STS2 Rural - Personnel & Company Summary Review (VicRoads Use Only)


Does the experience and qualifications of the employees comply with STS2 (Rural) level


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STS2

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STCE1

APPLYING FOR PUBLIC LIGHTING AND BASIC ELECTRICAL WORKS (STCE1) - YES NO Relevant Work Undertaken Public Lighting, installation and maintenance works Yes No Installation of electrical and communication conduit and pit work Yes No

Specific Eligibility Criteria Complies Minimum of two permanent full time employees that are holders of an Electrician’s License and

based at company’s office/depot. (Evidence that the staff are permanent such as payroll summary)Yes No

Minimum of three years relevant field experience within the last six years within this area of competency.

Yes No


Comments

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STCE1






NAMENAME OF THE




NOMINATED EMPLOYEE NAME: of 47 Rev. 2

STCE1




NAMENAME OF THE




Note: Add pages here for additional employees if required.

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STCE1

STCE1 Personnel & Company Summary (VicRoads Use Only)


Does the experience and qualifications of the employees comply with STCE1 level


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STCE2

APPLYING FOR OTHER ON-ROAD ELECTRICAL ITS DEVICES (STCE2) - YES NO (also STCE1 by default) Relevant Work Undertaken

Freeway Data Stations Yes No Help Phones Yes No Drive Time Yes No Electronic Signs Yes No Ice Warning Yes No Vehicle Height Yes No Public Lighting Yes No Bluetooth Data Stations Yes No Transmission Equipment Yes No


based at company’s office/depot. (Evidence that the staff are permanent such as payroll summary) Yes No Minimum of three years relevant field experience within the last six years within this area of

competency. Yes No Minimum number of two suitable vehicles. Yes No

Comments

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STCE2






NAMENAME OF THE




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STCE2





NAMENAME OF THE





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STCE2

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SCTV

APPLYING FOR SPECIALIST ON-ROAD ITS DEVICES (STCE3) - YES NO (does not cover STCE1 & STCE2) Relevant Work Undertaken

Yes No Yes No Yes No

Below is minimum STCE3 Specific Eligibility Criteria, these requirements might change based on the works the company is applying for.


based at company’s office/depot. (Evidence that the staff are permanent such as payroll summary) Yes No Minimum of three years relevant field experience within the last six years within this area of

competency. Yes No Minimum number of two suitable vehicles. Yes No

For a company to apply for this level, a VicRoads representative needs to identify the works as very specific and that they are not covered by other prequalification levels. List below ITS work type the company wishes to apply for.

Comments

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SCTV






NAMENAME OF THE




NOMINATED EMPLOYEE NAME: of 47 Rev. 2

SCTV




NAMENAME OF THE





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SCTV





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SCTV

APPLYING FOR COMMUNICATIONS (SCTV) - YES NO Relevant Work Undertaken CCTV Camera Network Systems Yes No CCTV Transmission Equipment Yes No CCTV Distribution & Termination Cabins Yes No

Specific Eligibility Criteria Complies Minimum of two permanent full time employees that are licensed in accordance with ACMA

requirements and based at company’s office/depot. (Evidence that the staff are permanent such as payroll summary)

Yes No

Minimum of one permanent full time employee that is holder of an Electrician’s License and based at company’s office/depot.

Yes No

Minimum of three years’ relevant field experience within the last six years within this area of competency.

Yes No


Comments

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SCTV






NAMENAME OF THE




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SCTV





NAMENAME OF THE





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SCTV

SCTV Personnel & Company Summary (VicRoads Use Only)

Summary provided by contractor Yes No Referees Check ConductedYes No

Does the experience and qualifications of the employees comply with SCTV level

Yes No Checked by VicRoads OfficerYes No Does the company have the facilities and required number of vehicles Yes No

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SVDL

APPLYING FOR VEHICLE DETECTOR (SVDL) METRO - YES NO (Includes Rural by default) Relevant Work Undertaken

Traffic Signals Yes No Freeway Data Stations Yes No Lane Delineation & Markings Yes No

Specific Eligibility Criteria Complies Minimum of two permanent full time employees that have relevant experience in the area of

competency. Such personnel shall be based at company’s office/depot; (Evidence that the staff are permanent such as payroll summary)

Yes No


Minimum number of two suitable vehicles in Metro area Minimum number of one suitable vehicle in Rural area. Yes No

Comments

PERSONNEL EXPERIENCE SUMMARY

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SVDL






NAMENAME OF THE





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SVDL




NAMENAME OF THE




SVDL Personnel & Company Summary (VicRoads Use Only)

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SVDL


Does the experience and qualifications of the employees comply with SVDL level


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SOED

APPLYING FOR SUPPLY OF ON-ROAD ELECTRICAL DEVICES (SOED) - YES NO VicRoads Type Approved Product

Variable Message Signs Yes No Traveller Information Signs Yes No Other Electronic Signs Yes No Environmental Warning Systems Yes No Other Electronic Signage Which is in common usage Yes No

Specific Eligibility Criteria Complies Minimum of one full time employee with Diploma of Electronics or equivalent. (Evidence that the

staff are permanent such as payroll summary)Yes No

History of project completion and delivery Yes No Competency in the manufacture and supply of signs (this is proven by attainment of VicRoads

type approval for a minimum of two current on-road electronic display, data collection or advisory equipment)

Yes No

Comments

PERSONNEL EXPERIENCE SUMMARY of 47 Rev. 2

SOED






NAMENAME OF THE




SOED Personnel & Company Summary (VicRoads Use Only)

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SOED


Does the experience and qualifications of the employees comply with SOED level

Yes No Checked by VicRoads OfficerYes No

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Plant and Premises

PLANT & PREMISES ASSESSMENT

Existing applicants: - please fill out and sign the declaration for Plant & Premises self-assessment checklist below (Please indicate how your company’s premises meet the criteria):

New applicants: - site inspection will be conducted after reviewing your application on the checklist below.

Item Criteria Description of Facility at Company Premises1. Does the company maintain a secure, suitable size lockable

depot in the works area for the purpose of storing goods and equipment relevant to the works?

2. Does the company maintain a manned office (staff of the company and not a third party) that is serviced during business hours for the purpose of receiving and relaying work instructions?

3. Does the company have a secure storage facility, electronic and manufacturing factory or workshop with the capability to supply on-road electronic devices including test facilities?

4. As nominated by the level, suitable vehicles that are equipped to readily undertake the works associated with the area of competency. (Excludes SOED)

Vehicle should be fitted with a minimum of;Flashing yellow lights, safety cones, first Aid Kit and Fire extinguisher. Evidence in form of picture and registration numbers needs to be provided in the application.

5. Does the company have appropriate design and development of 47 Rev. 2

Plant and Premises

capability?

6. Has the company previously supplied on-road electronic devices to VicRoads requirements?

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Company Declaration

Company Name:

Company Representative undertaking assessment

Name (print):

Signature:

Date of assessment:

I declare that the particulars shown herein are true and correct in every detail:

Signed: ……………………………………………………………………………

Name (print): ……………………………………………………………………

Position in Company: ………………………………………………………

Date: ……………………………………………….

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Declaration – to be made by a director or chief executive

VicRoads Use only

Referee Check Details - (VicRoads Use Only)

Summary provided by contractor: Yes No Checked by VicRoads Officer: Yes No Referees Remarks

Referees Name & Date of Works Work Type Comments SatisfactoryYes No Yes No Yes No Yes No Yes No

Standard Eligibility Criteria - (VicRoads Use Only)

The Contractor has demonstrated compliance with:Comment

a. the requirements described for personnel: Yes No b. the requirements described for the company: Yes No

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VicRoads Use only

RECOMMENDATION ( VicRoads Use only )

Company Name:Date:

Application: New Contractor Existing Pre-qualified Contractor

Assessment Rating

Level Applied For Rating CommentsSCTV Yes No STCE Yes No STS1 Yes No STS2 Yes No SVDL Yes No SOED Yes No

STS2(Rural only) Yes No

Ratings TableQualifies Does Not Qualify

Very Good Good Conditional Limited Poor Suspend1 2 3 4 5 6

VicRoads Officer:Date:

Business Area:Section:

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VicRoads Use only

CONDITIONAL PRE-QUALIFICATION - SUMMARY & RECOMMENDATION

ITEM DESCRIPTION RECOMMENDED CONDITION1

2

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