Road Surface Inspection Form
Date of Inspection
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Surveyed By
First Name
Last Name
Sample Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Asphalt/Pavement Inspection
Please check following distresses
Rows
Yes
No
Alligator Cracking
1
2
Bleeding
3
4
Block Cracking
5
6
Bumps and Sags
7
8
Corrugation
9
10
Depressioon
11
12
Edge Cracking
13
14
JT Reflection Cracking
15
16
Land/Shldr Drop Off
17
18
Long and Trans Cracking
19
20
Patching and Util Cut Patching
21
22
Polished Aggregate
23
24
Potholes
25
26
Railroad Crossing
27
28
Rutting
29
30
Shaving
31
32
Slippage Cracking
33
34
Swell
35
36
Weathering and Raveling
37
38
Please indicate severity level and value
Rows
Low
Medium
High
Severity Value
Alligator Cracking
39
40
41
Bleeding
42
43
44
Block Cracking
45
46
47
Bumps and Sags
48
49
50
Corrugation
51
52
53
Depressioon
54
55
56
Edge Cracking
57
58
59
JT Reflection Cracking
60
61
62
Land/Shldr Drop Off
63
64
65
Long and Trans Cracking
66
67
68
Patching and Util Cut Patching
69
70
71
Polished Aggregate
72
73
74
Potholes
75
76
77
Railroad Crossing
78
79
80
Rutting
81
82
83
Shaving
84
85
86
Slippage Cracking
87
88
89
Swell
90
91
92
Weathering and Raveling
93
94
95
Please indicate deduct value
Rows
Deduct Value
Alligator Cracking
Bleeding
Block Cracking
Bumps and Sags
Corrugation
Depressioon
Edge Cracking
JT Reflection Cracking
Land/Shldr Drop Off
Long and Trans Cracking
Patching and Util Cut Patching
Polished Aggregate
Potholes
Railroad Crossing
Rutting
Shaving
Slippage Cracking
Swell
Weathering and Raveling
Total Deduct Value
Additional information
Inspector Signature
Submit
Should be Empty: