Issue Number as seen Above
Where is the Issue? —Please choose an option—HospitalStreetCommunitySchoolOthers
[group OtherIssues clear_on_hide inline] Whats the Other Issue? [/group]
[group Hospital clear_on_hide inline] Whats Wrong at the Hospital? —Please choose an option—No medicineNo doctors / nurseRude StaffNot cleanOthers [/group]
[group HospitalName clear_on_hide inline] Name of Hospital / Clinic [/group]
[group HospitalLocation clear_on_hide inline] Hospital / Clinic Location [/group]
[group Street clear_on_hide inline] Whats Wrong in the Streets? —Please choose an option—Garbage not collectedStreet lights not workingBad roadNot cleanOthers [/group]
[group StreetName clear_on_hide inline] Name of Street [/group]
[group StreetLocation clear_on_hide inline] Street Location [/group]
[group Community clear_on_hide inline] Whats Wrong in the Community? —Please choose an option—Unclean waterUnsafe electrical wiringsBad roadBad drainageOthers [/group]
[group CommunityName clear_on_hide inline] Name of Community [/group]
[group CommunityLocation clear_on_hide inline] Community Location [/group]
[group School clear_on_hide inline] Whats Wrong at the School? —Please choose an option—No desksNo teachersUnclean environmentNo books for Pupils/StudentsOthers [/group]
[group SchoolName clear_on_hide inline] Name of School [/group]
[group SchoolLocation clear_on_hide inline] School Location [/group]
[cf7mls_step cf7mls_step-1 "Next" "Your Issue to Report"] Your name *
Your Gender * —Please choose an option—MaleFemalePrefer not to Say
Your Phone Number *
Your Age *
Do you want to Attach photos/videos? [mfile photo max-file:10]
Should we hide your Identity? —Please choose an option—YesNo
Note: Before reporting take a screenshot or memorise the Issue number on top. Keep it safe you can use it to track response to your issue, re-report it or give us feedback if the issue has been addressed before we take our actions.
[honeypot email validautocomplete:true move-inline-css:true "Your Email Address"]
[hakuna-matata]
[cf7mls_step cf7mls_step-2 "Back" "Your Details"]
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