Township Road Hazard Report
Who are you?
Name:
How can we reach you?
Phone:
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
Malfunction
Request
6. Remarks / Other
7. Submit
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