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 do not know what county the hazard is in
In what city/town is the hazard is located?
I do not know exactly what city/town it is in
The hazard is located:
:
inside city limts
outside of city limits
I do not know
Please choose one
The
roadway I was traveling on was:
Please choose one
the interstate
a city street
a state road or highway
a country road
an off/on ramp
a rural highway
a frontage road
a gravel road
a parking lot entrance
a parking lot exit
in a parking lot
other
The
name of the road I was traveling on is called:
The
closest crossroad to this road is called
The
hazard I encountered is:
Please choose one
a pothole or chuckhole
a very rough railroad track crossing
a slick or slippery roadway surface
sand
gravel
the 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
a 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
in an 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 identifying the hazard you have brought
to our attention:
Please type the LAST FOUR numbers only in the box below.
3151-1234
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