Technical Assistance Online Application

Agency Point of Contact Information

Mentoring Request

INSTRUCTIONS: Please describe the specific safety issue that your agency would like to address.

Safety Area (select one)

Please provide a description of the safety issue.

Is there crash data available from the location/segment?

Yes
No

If "Yes," please email data or any other supplemental information to Heather Rigdon, MATCH Coordinator, at MATCH@dot.gov.

What are the agency's goals or desired outcomes of the mentoring assistance?

Please provide some background on the history or projects related to the safety issue to be addressed.

Please describe any obstacles faced in previous mitigation efforts (if any).

Please list any specific countermeasures or strategies the agency is interested in implementing.

Is there any additional information or comments your agency would like to share as part of this technical assistance request?

Please indicate which format/s you are able to receive assistance.
Phone
Email
Video- or web-conference
Site visit (**Site visits may only be considered when remote ass1istance cannot provide the required assistance.**)

Does MATCH have permission to contact the respective State DOT or FHWA Division Office if needed to help support the agency's mentoring request?

Yes
No

A requesting agency (also known as the Mentee) is required to submit a summary report using a template provided by FHWA to describe the assistance after it is complete. Please mark "yes" to indicate your agency is willing to complete a summary report if this application for mentoring assistance is approved.

Yes
No