Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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MCC EMPLOYEE NAME AND PH #
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I agree with the above entered information to be true and accurate
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OTHER PARTIES INVOLVED NAME(s) AND PH #
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I agree with the above entered information to be true and accurate
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MCC DIRECT SUPERVISOR
WHO WAS ACCIDENT REPORTED TO
ARE THERE INJURIES
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YES, ENTER INJURIES BELOW
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NO
MCC VEHICLE OR EQUIPMENT INFO
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CLAIMANTS VEHICLE INFO
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WITNESS # 1 INFO
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I hereby agree to the above statement to the best of my eye witness recollection
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WITNESS # 2 INFO
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I hereby agree to the above statement to the best of my eye witness recollection
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ENTER ACCIDENT DESCRIPTION BELOW
WEATHER CONDITIONS
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DAYTIME
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NIGHTTIME
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WET, RAINING
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SNOWING
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ICY
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SUNNY AND DRY
TRAFFIC PATTERN
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One Way
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2 Lane Two Way
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Divided Highway, Enter lanes below
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DOWNLOAD SCENCE PICTURES BELOW
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IS THERE A POSTED SPEED LIMIT
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YES, ENTER BELOW
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NO, ENTER WHY
DRUG TEST REQUIRED
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YES, ENTER BELOW
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NO
ALCOHOL TEST REQUIRED
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YES, ENTER BELOW
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NO
MCC DRIVERS CDL AND FEDMED UP TO DATE
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YES
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IF NO, WHY?
IS A CLAIM BEING FILED
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YES
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NO, NOT AT THIS TIME
WERE POLICE CONTACTED
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YES, ENTER REPORT INFO BELOW
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NO
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PERSON FILLING OUT REPORT
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YES I WAS ON SITE OF THE ABOVE ACCIDENT
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I WAS NOT ON-SITE AND ENTERED AFTER THE FACT
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I hereby agree with the above information to be accurate, according to gathered statements and observations
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