Reporter’s full name *

Telephone number *

Address of the informant (if any)

Village No./Community *

Email (if there)

Preferred contact time (if any)

-- Select --Morning (08.00-12.00).Afternoon (12:00–16:00)Evening (16:00–20:00)Contact at any time

The name of the bridge (if any). *

Place/Point of Problem. *

Landmarks/Nearby Places

Bridge type (if known).

 Concrete bridge.   The Iron Bridge.   Wood bridge.   Other

Coordinates (if available)

Urgency *

-- Select --GeneralFairly urgent (affects access / travel)Highly urgent (hazard/accident).

Type of damage (select all that apply) *

 Damaged / cracked bridge deck

 Damaged / detached bridge railing

 Structure collapsed/inclined.

 Cracked bridge pier / foundation

 Damaged bridge approach / exit

 Other

Specify details (in other cases)

Date damage was found *

More Details *

The effect that occurred (if any).