First name:
Last name:
E-mail: I live in:	Choose a State Alabama Alaska Alberta Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
In what state is the hazard located?	Choose a State Alabama Alaska Alberta Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
In what county is the hazard located?
I was traveling:	North South East West
The roadway is:	Please choose one Interstate City street Country road Off/On ramp Rural highway Frontage road Gravel road Parking lot entrance Parking lot exit In a parking lot
The roadway I was on is called:
The closest crossroad to this roadway is called
The hazard I encountered is:	Please choose one A pothole or chuckhole A crack in the road A very rough railroad track crossing A slick or slippery roadway surface Sand Gravel A limb of a tree hanging in roadway An animal carcass A stop sign missing A stop sign down A stop sign obstructed by an object A stop sign defaced An obstacle blocking roadway An object obstructing view A stop light not working A flashing light not working A bump Uneven pavement Unmarked speedbump Construction hazard Other Please explain in detail or give any other details you feel are important about what type of hazard you encountered:
The hazard is located:	Please choose one in the right portion of the lane in the center portion of the lane in the left portion of the lane in the median on the right shoulder on the NW corner on the NE corner on the SW corner on the SE corner intersection Other Please explain in detail or give any other details you feel are important about where in or near the roadway the hazard you encountered is located:
Comments:	Please give us any other detailed information you feel would help us in locating and indentifying the hazard you have brought to our attention:
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