Water Main Break Report Form
Report a water main break with essential operational details to ensure timely response and repair.
Incident Location (Street address, intersection, or nearest landmark)
*
Date and Time of Break
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Type of Break Observed
*
Leak
Burst
Crack
Other
Severity of the Break
*
Minor (slow leak, minimal flooding)
Moderate (noticeable water flow, some flooding)
Major (heavy flow, significant flooding)
Visible Effects
*
Flooded street
Water bubbling from ground
Low water pressure nearby
Erosion or sinkhole
Other
Nearest Cross Streets or Landmarks
Estimated Area Affected (in meters or blocks)
Urgency Level
*
Immediate threat to safety/property
Needs prompt attention
Routine (no immediate risk)
Actions Taken (if any)
Called emergency services
Warned public/placed barriers
No action taken
Other
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