Type of Lighting Fixture:  Entrance Lighting  Hallway Lighting  Street Post  Traffic Signal Light  Traffic Signal Sign 

Location: 
(This should be the exact location)

Nearest Reference Point: 
Date of Notification:   (This will usually be today's date)

Date First Observed: 

Please indicate the general problem with the light or sign that you are reporting.  Broken  Fallen  Missing  Obstructed View  Other 

If other is selected, explain: 

Additional Information which you feel is needed:

or click on the  button to dispose of this form.