Township Road Hazard Report
Who are you?
How can we reach you?
Where is the Hazard?
I encountered a road hazard on (name of street)
on the N S E W side of the road,
approximately (distance) feet from
N S E W of (name of intersecting street)
When did you encounter it?
Time: a.m. p.m. Date:
What else can you tell us?
1. Surface
Gravel Road Rough Wash-out
  Dust Ice / snow
Pavement Hole(s) Settlement Edge Hole
  Sweeping Ice / snow    
2. Shoulder/Road Side
Hole(s) Wash-out Drop (edge of pavment) Vision Obstruction
3. Trees/Brush
Blocking road Hanging limbs Request removal
Vision Obstruction Blocking sign    
4. Drainage
Water over road Flooding private property Standing in ditch
Culvert / catch basin blocked Blocking sign    
5. Signs / Guard Rail / Signals / Pavment Markings
Lack of
Damaged / worn
6. Remarks / Other
7. Submit

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