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Bridge status change Form 107
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Team Leader Bridge Inspector Form

* Required information

I. Inspector contact information

First name of bridge inspector:*

Last name of bridge inspector:*

Email address:*

Phone number:*

(e.g. 555-123-4567)

Cell phone number:

(e.g. 555-123-4567)

Organization / agency / company:*

Address 1:*

Address 2:

City:*

State:*

ZIP code:*

II. License Information

Professional Engineer

YesNo

License number:

State:

Expiration Date:

Engineer-in-training (EIT)

YesNo

EIT certificate number:

Technician

YesNo

III. Bridge Inspection Training

Safety Inspection of In-Service Bridges, course number FHWA-NHI-130055:

(two-week course)

yes
no

Date:

(e.g. MM/DD/YYYY)

Safety Inspection of In-Service Bridges for Professional Engineers, course number FHWA-NHI-130056:

(five-day course)

YesNo

Date:

(e.g. MM/DD/YYYY)

Bridge Inspector Refresher Training, course number FHWA-NHI-130053:

(three-day course)

YesNo

Date:

(e.g. MM/DD/YYYY)

Fracture Critical Inspection Techniques for Steel Bridges, course number FHWA-NHI-130078:

(four-day course)

YesNo

Date:

(e.g. MM/DD/YYYY)

IV. Bridge Inspection Experience (required for non-professional engineers only)

Number of years inspecting bridges:

Number of bridges inspected annually in the presence of an NBIS qualified bridge inspector:

Total number of bridges inspected:

Question/comments:

Captcha Image (Security Code):

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