Commercially Useful Function Review – Field Form

Date:	Project Control Number:
Prime Contractor	Subcontractor:
Second-Tier Subcontractor:	Reviewer:
DBE Representative:

This form must be completed for each DBE subcontractor on a project. If the DBE is a subcontractor and has subcontracted work to a second-tier subcontractor, this form must be filled out for the second-tier subcontractor as well.

Please forward this form to the NDOT Civil Rights Office upon completion:

NDOT HCRO, 1500 Hwy 2, PO Box 94759, Lincoln, NE 68509-4759

Fax: 402-479-3728 Email: ndot.hcro-dbe@nebraska.gov

Yes	No	N/A

Is the DBE performing the work items that the firm is under contract to perform?
Is the DBE performing any additional work items?

Who is supervising the DBE’s work on the jobsite?

Yes	No	N/A

Has the DBE owner been present on the jobsite?
Is the DBE performing work with its own workforce?
Are employees of the prime contractor performing any of the DBE’s work?
Does the DBE on-site representative effectively manage the jobsite without any interference from the prime contractor?

List the major self-propelled (engine) equipment used by the DBE:

Is the equipment used by the DBE owned by the DBE firm, or leased?
Does the equipment have the DBE’s markings or emblems?

Yes	No	N/A

Is the equipment under the direct supervision of the DBE?
Is the operator of the leased equipment the DBE’s employee?
If the DBE is contracted to provide supplies, did the DBE actually deliver the supplies?

Yes	No	N/A

If the DBE is contracted for hauling, do the trucks used on the project belong to the DBE?

NDOT Form 136b, March 22