Title Page
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Document No.
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Vehicle Accident/Loss Investigation Report
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Conducted on
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Prepared by
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Incident Location
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Personnel involved in Incident
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Name of Driver
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Vehicle Unit Number
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Type of Vehicle
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Date Driver Last Certified on Above Vehicle
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Date of Incident
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Date the Accident/Injury was reported to the Safety Committee
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Location of Incident
Roadway (check all that apply)
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Strait?
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Curve?
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On Grade?
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Level?
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Hillcrest?
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Dry?
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Wet?
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Muddy?
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Snowy?
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Icy?
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Sleet?
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Oily?
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2-lane?
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3-lane?
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Divided?
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Rural?
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Other?
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Photo Documentation
Accident Occurred: (check all that apply)
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At the Fire Station?
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Responding to an emergency?
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At the emergency scene?
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Returning from an emergency?
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Training?
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Convention or parade?
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Other?
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Photo Documentation
Type of loss (check all that apply)
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Personal Injury
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Property Damage
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Vehicle Damage
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Photo Documentation
Weather
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Clear?
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Rain?
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Snow?
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Fog?
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Other?
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Photo Documentation
Description of Accident
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Description of Accident
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Photo Documentation
Motor Vehicle Diagram
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Draw Roadway, Vehicles or items involved, etc.
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Photo Documentation
Safety Analysis
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What acts, failures to act and/or conditions contributed most directly to this accident? (Immediate cause)
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What are the basic or fundamental reasons for the existence of these acts and/or conditions? (fundamental cause)
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What action has or will be taken to prevent recurrence? Place an "X" by items already completed?
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Safety Supervisors Comments
Signatures
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Driver's Signature
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Date
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Supervisor's Signature
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Select date
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Safety Supervisor's Signature
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Select date
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Photo Documentation
