Accident Incident Report Form

• Name of injured person

• Conducted on (Date and Time)

  Date

• Fleet manager full name

• Incident location
  Address

General Information

• Name of driver

• Driver's license number

• Car registration number

Injured Person Background

• Identification number

• Take photo of ID

  Media

• Gender

  Male

  Female

• Date of Birth

• Telephone Number

• Address
  Address

Injury Details

• Date and time of event

  Date

• What part of the body was injured? Describe in detail

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

  Media

• Describe fully how the accident happened?

• Take photo of the surrounding

  Media

• Were safety regulations in place and used?

  Yes

  No

  N/A

• What was wrong?

Witness Statements

• Were there any witnesses?

  Yes

  No

• Add witness

Witness

• Enter witness name

• Contact number

• Witness statement

• Witness signature

  Sign

Emergency Services

• Employee went to doctor/ hospital?

  Yes

  No

• Doctor's Name

• Hospital Name

• Police were called to the scene

  Yes

  No

• Police reference number

Sign off

• Injured person (Full Name and Signature)

  Sign

• Fleet manager (Full Name and Signature)

  Sign