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Department of Transportation
SIIMS
Team Leader Bridge Inspector Form
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Required information
I. Inspector contact information
First name of bridge inspector:
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Last name of bridge inspector:
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Email address:
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Phone number:
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(e.g. 555-123-4567)
Cell phone number:
(e.g. 555-123-4567)
Organization / agency / company:
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Address 1:
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Address 2:
City:
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State:
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ZIP code:
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II. License Information
Professional Engineer:
Yes
No
License number:
State:
Expiration Date:
Engineer-in-training (EIT):
Yes
No
EIT certificate number:
Technician:
Yes
No
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):
Yes
No
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):
Yes
No
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) :
Yes
No
Date:
(e.g. MM/DD/YYYY)
Upload certificate of training for FHWA-NHI-130078:
IV. Bridge Inspection Experience
Number of years inspecting bridges:
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Total number of bridges inspected in the presence of an NBIS qualified bridge inspector:
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Question/comments:
Captcha Image (Security Code):
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