Streetlight Outage Report

Purpose: This form is intended to help residents report non-functional or damaged streetlights to their local Public Works or Transportation department for repair or maintenance.

Reporter Information

Full Name: {fullName}

Phone Number: {phoneNumber}

Email Address: {email}

Preferred Contact Method: {preferredContact}

Streetlight Details

Location of Streetlight: {location}

Nearest Landmark or Cross Street: {landmark}

Pole Number (if visible): {poleNumber}

Issue Description

Type of Issue:

• {issueType}

Detailed Description:

{description}

{#photos}

Attached Photo(s):

• {%photo}

{/photos}

Outage Timing

When did you notice the outage? {dateNoticed}

Is the outage ongoing? {isOngoing}

Has this issue been reported before? {priorReport}

{#priorReportDetails}

Details of Previous Report:

{details}

{/priorReportDetails}

Additional Notes or Comments

{additionalComments}

Affected Locations (if multiple)

{#affectedAreas}

• Location: {location} — Pole Number: {poleNumber}

{/affectedAreas}

Signature

Submitted by: {fullName}

Date of Submission: {submissionDate}