Washington State
Department of Transportation

Roadway Damage Report Form

1. Date
 2. Time
 Status
       3. Open     4. Lane closure      5. Restricted     6. Full Closure
 7. Region
  		8. County

  9. Route
 10. Milepost
 11. Direction
12. Location:

 13. Inspector's Name
 
14. Remarks
  
Roadway
Geo-technical Issues
15. Cracking
23. Shoulder settlement
16. Buckling
24. Sags in roadway safety features (guardrail)
17. Heaving or rolling
25. Movement above or below tilted trees
18. Pavement separation
26. Debris on roadway
19. Change in configuration- striping or lane shift
27. Sloughing slopes
20. Change in roadway surface
21. Signs, VMS and sign bridges
22. Drainage
Communications Log
Sending Station
Receiving Station
Radio frequency MHZ
Time Sent/Recieved (local)

DOT Form 410-005 Revised 10/2022

             Version 1.1