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Audit

General Information

Name of driver

Driver's license number

Car registration number

Injured Person Background

Identification number

Take photo of ID

Gender

Date of Birth

Telephone Number

Address
Injury Details
Date and time of event

What part of the body was injured? Describe in detail

Take photo of the body part that was injured. Annotate as required

Describe fully how the accident happened?

Take photo of the surrounding

Were safety regulations in place and used?

What was wrong?

Witness Statements

Were there any witnesses?

Add witness

Witness

Enter witness name

Contact number

Witness statement

Witness signature
Emergency Services

Employee went to doctor/ hospital?

Doctor's Name

Hospital Name

Police were called to the scene

Police reference number

Sign off
Injured person (Full Name and Signature)
Fleet manager (Full Name and Signature)

Accident Incident Report Form Checklist

Created by: SafetyCulture Staff | Industry: General | Downloads: 78

An accident incident report form is used when someone got injured as a result of collision. This template can be used by fleet managers to document the details of the incident. Use this template to guide the inspector to perform the following: 1. Capture all contact details and verification information of the injured person 2. Describe full details of the injury and the accident 3. Take photo evidence of the surroundings 4. Record emergency services involvement (i.e. police, fire, paramedics), hospitalization information and witness statements 5. Capture electronic signatures from the relevant person involved and injured person

Signup for a free iAuditor account to download and edit this checklist. It will be added to your free account and you will be able to conduct inspections from your mobile device.

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Audit

General Information

Name of driver

Driver's license number

Car registration number

Injured Person Background

Identification number

Take photo of ID

Gender

Date of Birth

Telephone Number

Address
Injury Details
Date and time of event

What part of the body was injured? Describe in detail

Take photo of the body part that was injured. Annotate as required

Describe fully how the accident happened?

Take photo of the surrounding

Were safety regulations in place and used?

What was wrong?

Witness Statements

Were there any witnesses?

Add witness

Witness

Enter witness name

Contact number

Witness statement

Witness signature
Emergency Services

Employee went to doctor/ hospital?

Doctor's Name

Hospital Name

Police were called to the scene

Police reference number

Sign off
Injured person (Full Name and Signature)
Fleet manager (Full Name and Signature)