Name and surname of the person reporting *

Phone number *

Reporting party's address (if applicable)

Neighborhood/Community *

Email (if applicable)

Preferred contact times (if applicable)

-- Select --Morning (08:00–12:00)Afternoon (12:00-16:00)Evening (16:00–20:00)Available for contact at any time.

Bridge name / Local name (if applicable) *

Location/Area of the Problem *

Points of interest/Nearby locations

Type of bridge (if known)

 Concrete bridge   Steel bridge   Wooden bridge   Other

Coordinates (if available)

Urgency *

-- Select --GeneralRequires immediate attention (as it affects traffic).Urgent (potential danger/accident)

Types of Damage (select as many as apply) *

 The bridge surface is damaged/cracked.

 Damaged/broken bridge

 Foundation is cracked/leaning

 Bridge pier/foundation cracked

 The bridge has damaged access points for both ascending and descending.

 Other

Provide details (for other cases)

Date of damage discovery *

More details *

Any effects that may occur (if any)