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Road and Utility Status Report
Report all road damages or closures due to damaged power lines on this form.
Street/Road Name and Number
*
Ex. 123 Main St
Name of Municipality
Date/Time Reported
MM
/
DD
/
YYYY
HH
:
MM
AM
PM
AM/PM
Map Coordinates (UTM, USNG/MGRS or LAT/Long)
Datum should be NAD83. UTM/MGRS preferred.
LAT/Long in decimal degrees (DD.dddd°).
Road Type
State Route
Town
Private
Road Passable?
Both Lanes Open
One Lane Open
All Lane Closed
Road Damage
Road Damaged
Road Flooded
Blocked by Accident
Bridge Damaged
Culvert Damaged
Blocked by Debris
Utility Problem
Electrical Wire
Telephone
Cable
Utility Pole
Transformer
On Fire
Lying in Road
Hanging Low over road
Trees in Wires
People Trapped
Lying alongside road
Danger to Public
Name of Person Reporting
Phone #
Email Address to reply to
Any other Information?
Attach photo
Add File
