Department for Planning and Infrastructure - Government of Western Australia
 
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Hazard Report Form

This form is for use in Western Australia only.

The Department for Planning and Infrastructure will forward all details provided in this form to the responsible body, eg local authority, Main Roads WA, and ask them to provide a progress report directly to the person reporting the hazard.

Please be as specific as possible in describing the location of the hazard.

LOCATION

Road  Shared Path  
Suburb:               
Street Name:          
Intersecting Street:  
Nearest Landmark:       

DESCRIPTION OF HAZARD
  
Pothole              Bump               Sand on Surface 
Grass on Surface     Broken glass       Overhanging branches 
Grab rail            Kerb ramp (give details below) 
Drainage grate       Traffic light sensor not responding to cyclists
Caltrop thorns (double gees)  Other   

Comments/Suggestions:  

  

REPORTED BY  

Name:       Date:  
Street:    
Suburb:     Postcode:  
Email:     
Phone:    (H)           
          (W)  

  

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Department for Planning & Infrastructure