Highway Hazard Identification Checklist Form
Report hazards observed on highways quickly and accurately. Please provide as much detail as possible to help ensure timely response and resolution.
Type of Hazard Observed (Select all that apply)
*
Debris or fallen objects
Potholes or damaged pavement
Obstructed signage
Flooding or standing water
Damaged guardrails or barriers
Animals on roadway
Other
Describe the Hazard
*
Location of Hazard (provide nearest mile marker, exit, or landmark)
*
Severity of Hazard
*
Low - Minor inconvenience
Medium - Potential safety risk
High - Immediate danger
Date and Time Observed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Upload a Photo (optional)
Upload a File
Drag and drop files here
Choose a file
Cancel
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Your Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Your Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Hazard Report
Should be Empty: