REQUEST FOR INSPECTION OF MATERIAL

CDOT Project No: Date:

MUST BE COMPLETED
Project Description:

IDOT Contract No:

Resident Engineer:
Resident Engineer assigns the T-Number and Project Completion Date:
retains a record in the job file. RE must send one
completed copy, with supporting documentation, General
to CDOT Quality Assurance 30 N. LaSalle, Suite Contractor:
400 Chicago, IL 60602 for processing. Subcontractor:

PAY ITEM NO. PAY ITEM DESCRIPTION MATERIAL DESCRIPTION QUANTITY UNIT

MUST BE COMPLETED

PRODUCER/ SUPPLIER CERTIFICATION (Only one Producer/Supplier per Inspection Report)

I hereby certify that the items listed above to be used
PRODUCER:
in construction of the subject project comply with all
PRODUCER CODE: contract requirements including Buy America,
Buy American or Steel Products Procurement
LOCATION: Act of IL when required.

SUPPLIER: Certified by:

SUPPLIER CODE: Name:

LOCATION: Signature:

IDOT INSPECTION (Attach a copy of all applicable evidence of inspection and supporting documentation)
This material has been inspected by the Illinois Department of Transportation and they have provided the following Evidence of Material
Inspection: IL OK Stamp No. ; Tag; LA-15.
Inspector No.: Inspector Name: District No.:

CDOT QA INSPECTION (Attach a copy of all applicable evidence of inspection and supporting documentation)
This material has been inspected by CDOT QA and has been found acceptable based upon the project specifications.

Printed Inspector Name: Company:

Signature of Inspector: Date:

ENGINEER ENDORSEMENT (Check all that apply and attach a copy of all applicable evidence of inspection and supporting
ENGINEER COMPLETES

documentation)
This material complies with the requirements of the project specifications and is accepted on the basis of: Visual Inspection;
Producer Certification; IDOT Approved Source; Source having furnished similar material found acceptable under CDOTs
normal testing procedures; IDOT Inspection; CDOT QA Inspection; Approved Submittal;
Mark (Detail) .
The above material was inspected on
Date Inspection
Approved by:
Report T-
Engineer
Page of
This RFIM has been Reviewed by CDOT QA and has been found Acceptable. No.:
Reviewer: Date:
cc: Contractor
CDOT QA Revised 04/12
REQUEST FOR INSPECTION OF MATERIAL
CDOT Project No: 1 Date: 2
 Project Description: 3

MUST BE COMPLETED
IDOT Contract No: 4

Resident Engineer: 5
Resident Engineer assigns the T-Number and Project Completion Date: 6
retains a record in the job file. RE must send one
completed copy, with supporting documentation, General 7
to CDOT Quality Assurance 30 N. LaSalle, Suite Contractor:
400 Chicago, IL 60602 for processing. Subcontractor: 8

PAY ITEM NO. PAY ITEM DESCRIPTION MATERIAL DESCRIPTION QUANTITY UNIT
9 10 11 12 13
MUST BE COMPLETED

PRODUCER/ SUPPLIER CERTIFICATION (Only one Producer/Supplier per Inspection Report)

I hereby certify that the items listed above to be used
PRODUCER: 14
in construction of the subject project comply with all
PRODUCER CODE: 15 contract requirements including Buy America,
Buy American or Steel Products Procurement
LOCATION: 16 Act of IL when required.

SUPPLIER: 17 Certified by: 20

SUPPLIER CODE: 18 Name: 21

LOCATION: 19 Signature: 22

IDOT INSPECTION (Attach a copy of all applicable evidence of inspection and supporting documentation)
This material has been inspected by the Illinois Department of Transportation and they have provided the following Evidence of Material
Inspection: IL OK Stamp No. 23 ; Tag; LA-15.
Inspector No.: 24 Inspector Name: 25 District No.: 26

CDOT QA INSPECTION (Attach a copy of all applicable evidence of inspection and supporting documentation)
This material has been inspected by CDOT QA and has been found acceptable based upon the project specifications.

Printed Inspector Name: 27 Company: 28

Signature of Inspector: 29 Date: 30

ENGINEER ENDORSEMENT (Check all that apply and attach a copy of all applicable evidence of inspection and supporting
ENGINEER COMPLETES

documentation)
This material complies with the requirements of the project specifications and is accepted on the basis of: Visual Inspection;
Producer Certification; IDOT Approved Source; Source having furnished similar material found acceptable under CDOTs
normal testing procedures; IDOT Inspection; CDOT QA Inspection; Approved Submittal;
Mark (Detail) 31 .
The above material was inspected on 32
Date Inspection
Approved by: 33
Report T- 34
Engineer
Page 37 of
This RFIM has been Reviewed by CDOT QA and has been found Acceptable. No.:
Reviewer: 35 Date: 36
cc: Contractor
CDOT QA Revised 04/12
INSTRUCTION FOR THE REQUEST FOR INSPECTION OF MATERIAL FORM

This form is to be completed by the Contractor when requesting material inspection for all materials on the project, with
the exception of hot mix asphalt (HMA) and concrete (PCC). This completed form must be accompanied by the required
documentation including, but not limited to manufacturer certification, mill analysis reports, LA-15, bills of lading,
shipping tickets. This form and all the supporting documentation must be submitted to the Resident Engineer prior to the
material being incorporated into the project.
ITEM INSTRUCTION
1. City of Chicago Project Number
2. Date that the Request for Inspection of Material is generated
3. Project Description
4. IDOT Contract Number (if applicable)
5. Consultant Resident Engineer or City of Chicago Resident Engineer (if there isnt a Consultant Resident Engineer
for the Project).
6. Project Completion Date
7. Project General Contractor
8. Subcontractor performing the work (if applicable)
9. Contract Pay Item Number (example: 50)
10. Pay Item Description (example: Catch Basin, Type C, Type 1 Frame, Open Lid)
11. Material Description ( example: Type 1 Frame Open Lid)
12. Quantity of material being inspected
13. Unit of Measure (examples: Each, Ton, SQ FT.)
PRODUCER/SUPPLIER CERTIFICATION
14. The Producer of the material
15. The Producers Code which is found in IDOTs MISTIC Producer List (Note: If the material being produced is from
a approved City of Chicago source and/or a Contract specified source which is not found in IDOTs MISTIC
Producer List leave the line blank.)
16. The location where the material is being produced
17. The Supplier of the material
18. The Supplier Code which is found in IDOTs MISTIC Producer List (Note: If the material being supplied is from an
approved City of Chicago source and/or a Contract specified source which is not found in IDOTs MISTIC
Producer List leave the line blank.)
19. The location where the material is being supplied from
20. Company Certifying the Material (Producer, Supplier, or Contractor) If the Supplier or Contractor is certifying the
material a copy of test result(s) and/or a letter of certification from the Producer should be attached.
21. Name of person Certifying the Material
22. Signature of person Certifying the Material
IDOT INSPECTION This section is completed when IDOT performs the source inspection, such as structural steel
fabrication, reinforcement bar, and etc. All supporting documentation shall be attached to the RFIM.
23. Insert the number found on the IL OK stamp.
24. Inspectors number, if given on the tag or from the LA-15.
25. IDOT Inspectors name.
26. Date on which the material was inspected.
CDOT QA INSPECTION This section is completed when CDOT QA performs source inspection, such as structural
steel fabrication. This RFIM should accompany the material from the source to the project site. All supporting
documentation shall be attached to the RFIM.
27. Inspectors Name (Printed)
28. The name of the Company the QA Inspector works for.
29. Signature of the QA Inspector
30. Date the inspection was made or the material was released by the inspector for shipment to the project site.
ENGINEER ENDORSEMENT
31. When MARK is checked, details describing the characteristics of the mark are required (i.e. Tag, Label, Physical
Mark, etc.)
32. Date the material was inspected by the Resident Engineer.
33. Resident Engineer signature, followed by printed name.
34. RE to assign T-number in sequential order.
35. Signature of the CDOT QA Reviewer. This is the person who has reviewed the RFIM submitted by the Resident
Engineer, along with the accompanying documentation, and has verified that the submittal is complete and
correct.
36. Date the acceptance of material inspection documentation.
37. If creating multiple pages under a single T number fill in each page number sequentially and indicate the total
number of RFIM pages utilized in the submittal. For single paged RFIM submittals always indicate Page 1 of 1.