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Missouri Department of Transportation

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Forms for Contractor Use 

Construction and Contractor Related

Affidavit for Compliance with Prevailing Wage Law (117 kb, 1 page)
ADA Checklist (10.3 mb,19 pages)
Certified Payroll Form (216 kb, 1 page)
Contractor Affidavit Regarding Settlement of Claims  (C-242) (50 kb, 1 page)
Contractor Nuclear Density Form (68 kb, 2 pages)
Contractor Performance Questionnaire - 2016 (94 kb, 13 pages)
CUF Determination Form (650 kb, 1 page)
Lead Abatement MODOT Contractor Informational Packet (50 kb, 1 page)
Lead Abatement MODOT FA Project Notification (69 kb, 1 page)
Lead Abatement MODOT Project Notification (78 kb, 1 page)
Lead Abatement MODOT Project Re-Notification (73 kb, 1 page)
Lead Abatement Program Contact Info (25 kb, 1 page)
OJT 1, Training Notification New button (133 kb, 1 pages)
OJT 2, Contractor Monthly Trainee Report New button (1.1 mb, 1 pages)
OJT 3, Training Completion New button (148 kb, 1 pages)
OJT 4, Trainee Contact New button (129 kb, 1 pages)
OJT 5, Discrimination Complaint New button (105 kb, 1 pages)
OJT 6, Training Summary New button (1.1 mb, 1 pages)
Request to Subcontract Work (C-220) (1093 kb, 2 pages)
Subcontractor Certification Regarding Affirmative Action (100 kb, 1 page)
Value Engineering Proposal  (C-104) (139 kb, 2 pages)
Contractor Questionnaire (24 kb, 2 pages)
DBE Identification Submittal Form (Open in Internet Explorer) (5.8 mb, 144 pages)
Prequalification Questionnaire (115 kb, 5 pages)
Wage Flowchart for Federal Jobs - Precon (9 kb, 1 page)
Wage Flowchart for State Jobs - Precon (8 kb, 1 page)
2AA Sheet - Blank (47kb, 1 page)
2AA Sheet - Example (114kb, 1page)
Waste Disposal Agreement 264kb, 1 page  Electronically fillable
FHWA Form 1589 Contractor Employment Report Link to FHWA website
DBE Contractor/Subcontractor Project Trucker and Equipment List New button (315 kb, 3 pages)
DBE Contractor/Subcontractor Project Trucker and Equipment List - Instructions New button (381 kb, 1 page)
Monthly Workforce Reporting Report  
Initial Workforce Diversity Plan  
DBE Substitution Form  
   

 

Federal Aid Posters

Job Site Bulletin Board Checklist
Letter Appointing EEO Officer
Equal Employment Opportunity (EEO) Policy - Example
Equal Employment Opportunity is the Law (English)
Equal Employment Opportunity is the Law (Spanish)
Employee Rights Under Davis Bacon WH-1321 (English)
Employee Rights Under Davis Bacon WH-1321 (Spanish)
Job Safety & Health Protection (OSHA 3165) (English)
Job Safety & Health Protection (OSHA 3167) (Spanish)
Notice to Workers Disability Paid at Special Minimum Wage WH-1284
Your Rights Federal Minimum Wage WH-1088 (English)
Your Rights Federal Minimum Wage WH-1088 (Spanish)
Notice to Employees Polygraph Protection Act WH 1462 (English)
Notice to Employees Polygraph Protection Act WH 1462 (Spanish)
Your Rights Family Medical Leave Act (FMLA) of 1993 WH-1420 (English)
Your Rights Family Medical Leave Act (FMLA) of 1993 WH-1420SP (Spanish)
Notice FHWA 1022 Title 18
Uninformed Services Employment and Reempolyment Rights Act (USERRA)
Pay Transparency Nondiscrimination Provision (English)
Pay Transparency Nondiscrimination Provision (Spanish)
Federal Wage Rate (Order/Determination). See Contract.

 

State Aid Posters

 

Discrimination in Employment is Prohibited by Law in Missouri MCHR-09 (English)
Discrimination in Employment is Prohibited by Law in Missouri MCHR-09 (Spanish)
Workers Compensation Law WC 106 (English)
Workers Compensation Law WC 106 (Spanish)
Storm Water Permit "Sign"
Discrimination in Public Accommodations MCHR-07 (English)
Discrimination in Public Accommodations MCHR-07 (Spanish)
Unemployment Benefits Law MODES B-2 (English)
Unemployment Benefits Law MODES B-2 (Spanish)
 

 

Materials  Related

 

Asphalt Mix Design Submittal Form v2.2 (464 kb, multiple page)
Buy America Materials of Origin Form New button  
Concrete Mix Design Submittal Form (76 kb, 1 page)
Corelok Aggregate Workbook (56 kb, 1 page)
Durable Aggregate Calculation (25 kb, 1 page Excel)
Illinois Flexibility Index Test  
New Product Evaluation Form (160 kb, 5 pages)  
PAL Program Inclusion Certifications and Guarantee Statement (122 kb, 1 page)
PAL Fabricators Receival Form (42 kb, 1 page)
PAL Shippers Transmittal Form (37 kb, 1 page)
Pipe Shipping Submittal Form:  CMP, RCP, Precast Drainage Unit & Precast Box Culvert 52 kb, 1 page)
Pipe Shipping Submittal Form:  Thermoplastic (64 kb, 1 page)
Producer Supplier Listing Form (148 kb, 4 page)
Recycle Binder Contribution v2.12 (116 kb, 1 page)
Recycle Binder Contribution (Section 401)  v2.20 (116 kb, 1 page)
Section 1040, 1043, and 1044 Inclusion Certification Statement  (17 kb, 1 page)
Section 1040, 1043, and 1044 Shipping Report Form (140 kb, 1 page)
Transfer Request of Inspected Material (25 kb, 1 page)
   

 

Utility / Right of Way  Related

 

Permit to Work on Right of Way
MoDOT Notice of Intent to Perform Work

 

 


The documents are provided in Acrobat Reader format. Free Acrobat Reader download PDF Icon
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Missouri Department of Transportation
Central Office
105 W. Capitol Avenue
Jefferson City, MO 65102
1-888-ASK-MODOT (275-6636)
1-866-831-6277 (Motor Carrier Services)
Driver's License Offices
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Missouri State Government
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