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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)

Upload training certificate for FHWA-NHI-130055:

Safety Inspection of In-Service Bridges for Professional Engineers, course number FHWA-NHI-130056: (five-day course):
YesNo

Date:

(e.g. MM/DD/YYYY)

Upload certificate of training for FHWA-NHI-130056:

Bridge Inspector Refresher Training, course number FHWA-NHI-130053: (three-day course):
YesNo

Date:

(e.g. MM/DD/YYYY)

Upload certificate of training for FHWA-NHI-130053:

Bridge Inspection Techniques for Nonredundant Steel Tension Members (NSTM), course number FHWA-NHI-130078: (three-day course) :
YesNo

Date:

(e.g. MM/DD/YYYY)

Upload certificate of training for FHWA-NHI-130078:

IV. Bridge Inspection Experience

Number of years inspecting bridges:*

Total number of bridges inspected in the presence of an NBIS qualified bridge inspector:*

Question/comments:

Captcha Image (Security Code):*

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