Title Page
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Medi 4 ROAD TRAFFIC ACCIDENT REPORT FORM
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WHAT TYPE OF Incident is this ?
- FATAL Injury at Scene
- Serious Injury-Possible Fatal
- Serious Injury-Life Changing
- Serious Injury-Fracture (#) excl-Nose
- Serious Injury-Lacerations-Suturable
- Hospital Ward Admission
- Minor Injury - #Nose
- Minor Injury- Laceration NO Sutures
- Minor Injury - Bruising
- Minor Injury - Shock
- Minor Injury - Whiplash?
- DAMAGE ONLY
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Document No.
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CALL SIGN and REGISTRATION of Service Vehicle Involved.
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Accident Location to nearest road junction
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Report Commenced at :
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Name of Person & PIN of person preparing report - Ideally Driver of Company vehicle unless incapacitated.
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Location
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Name of Attendant or Driver including PIN, where attendant is completing form
INSURED (SERVICE) VEHICLE
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Vehicle Make
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Please state exact vehicle Make and Model
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VEHICLE REGISTRATION NUMBER
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TRY TO PHOTGRAPH THE WHOLE VEHICLE, From a distance of approximately 10 Metres.
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PHOTOGRAPH VEHICLE FRONT
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PHOTOGRAPH FRONT OFFSIDE 3/4 - (DIAGONAL TO FRONT OFFSIDE CORNER)
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PHOTOGRAPH FRONT NEARSIDE 3/4 - (DIAGONAL TO FRONT NEARSIDE CORNER)
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PHOTOGRAPH VEHICLE OFFSIDE (DRIVERS)
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PHOTGRAPH VEHICLE NEARSIDE (PASSENGERS)
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PHOTOGRAPH VEHICLE REAR
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PHOTOGRAPH REAR OFFSIDE 3/4 - (DIAGONAL TO REAR OFFSIDE CORNER)
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PHOTOGRAPH REAR NEARSIDE 3/4 - (DIAGONAL TO REAR NEARSIDE CORNER)
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PHOTOGRAPH THE SCENE OF THE ACCIDENT - From 25metres from the direction of approach.
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PHOTOGRAPH THE SCENE OF THE ACCIDENT - From 25metres from the direction you are travelling towards.
DRIVER'S DETAILS
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FIRST NAME
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SURNAME
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Service PIN Number:-
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DATE OF BIRTH (dd/mmm/yyyy)
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DRIVING LICENCE NUMBER (16Numbers)
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DATE PASSED UK TEST (dd/mmm/yyyy)
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START OF DUTY TIME
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FINISH DUTY TIME
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JOB/CAD NO :- If applicable
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IS Sight Corrected ?
- Glasses - WORN at Time
- Glasses - NOT WORN at Time
- Contact Lenses - WORN
- Contact Lenses- NOT Worn
- Surgical Correction
- Laser Correction < 2yrs
- Laser Correction >2yrs
- None
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RESOURCE MANNING
WITNESS DETAILS
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ATTENDANT FULL NAME :- (if no attendant write n/a)
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ATTENDANT PIN Number :- (if no attendant write n/a)
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Was a patient being conveyed at the time of the Incident?
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WITNESS 1. Full Name
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WITNESS 1 Address Inc:- Post Code
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WITNESS 1. Contact Phone Number
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WITNESS 1. Email Address
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WITNESS 2. Full Name
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WITNESS 2. Address Inc:- Post Code
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WITNESS 2. Contact Phone Number
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WITNESS 2. Email Address
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WITNESS 3. Full Name
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WITNESS 3. Address Inc:- Post Code
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WITNESS 3. Contact Phone Number
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WITNESS 3. Email Address
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If particulars taken by Police Officer, Shoulder No:-
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Station Reported at :
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POLICE SERVICE (FORCE AREA):
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DID the police attend the scene?
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Was a Statement Taken by the Police?
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Did a manager attend the scene ?
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IF YES , Which manager attended?
OTHER VEHICLE / PROPERTY / ANIMAL
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IF a vehicle is involved please complete details below, if not move to PHOTOGRAPHS and Text Description
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Vehicle Make
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Vehicle Model (Normally on vehicle rear)
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INSURANCE Company name (Other vehicle)
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INSURANCE Contact Number (Other Vehicle)
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INSURANCE POLICY Number (Other Vehicle)
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Take a photograph from the front Offside corner (approximately 5 Metres from vehicle)
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Take a photograph from the front nearside corner (approximately 5 Metres from vehicle)
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Take a photograph from the Rear Offside corner (approximately 5 Metres from vehicle)
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Take a photograph from the rear nearside corner (approximately 5 Metres from vehicle)
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Please include any further information you feel may help.
OTHER DRIVER'S DETAILS
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First Name
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Surname
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Address details inc:- Post Code
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Contact Phone No:- (include as many numbers as possible leaving a double space between numbers)
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Email Address:-
INJURED PERSON(S)
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First Name
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Surname
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Address Details inc Post Code
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Contact Phone No(s)
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Email Address
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Please Photograph any visible injuries (with the patients consent- Do not compromise care to do this)
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Please describe any injury(s) that the person is complaining of.
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First Name
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Surname
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Address Details inc Post Code
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Contact Phone No(s)
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Email Address
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Please Photograph any visible injuries (with the patients consent- Do not compromise care to do this)
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Please describe any injury(s) that the person is complaining of.
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First Name
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Surname
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Address Details inc Post Code
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Contact Phone No(s)
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Email Address
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Please describe any injury(s) that the person is complaining of.
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Please Photograph any visible injuries (with the patients consent- Do not compromise care to do this)
PREVAILING CONDITIONS AT TIME OF INCIDENT
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Natural Light
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Street Lights
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Traffic
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Estimated Speed at Time of Collision (MPH)
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Audible/Visual Warnings or Devices.
- Blue Lights
- Amber (Airport) Light
- Sirens
- Headlamp Flasher(s)
- Rear Reds
- Hazard Lights
- Vehicle Horn
- Verbal
- None
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Road Conditions
- Dry
- Wet (Raining)
- Frost / Ice
- Snow
- Mud / Slush
- Flood / Water on Road
- Other
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Please describe the Road conditions.
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Journey Type
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Weather Conditions
- Clear
- Misty
- Foggy
- Rain
- Snow
- Other
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Please describe the Weather Conditions.
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Please describe the Weather Conditions.
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Road Type
- Motorway
- Dual Carriageway
- Single Carriageway (either way)
- One Way Street
- Filter Lane
- Other
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Please describe the Road type present at the scene.
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What Lights were used?
- Side Lights
- Dipped
- Main Beam
- Fog Lights Front
- Fog Lights Rear
- None
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What Lights were used by the Third Party Vehicle ?
- Side Lights
- Dipped
- Main Beam
- Fog Lights Front
- Fog Lights Rear
- None
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Third Party Involvement
- No Involvement
- Vehicle
- Motorcycle
- Pedestrian
- Cycle
- Property
- Animal(s)
- Street Furniture
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Please use this space to provide additional details if there are more than one, Third party, or if there is additional pertinent information not covered above.
LOCATION INFORMATION
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LOCATION of Accident
- More than 20m from a junction
- Side road on right
- Side road on left
- T - Junction
- Crossroads
- Traffic Light Controlled junction
- Roundabout
- Pedestrian Crossing
- within Hospital / Service property
- Scene of Incident
- Other
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Please describe other road features which are present at the accident scene. ie Cycle lanes, Construction work, Temporary light etc
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Vehicle Type
- Accident & Emergency
- High Dependency
- Patient Transport
- Wheelchair Accessible
- Rapid Response
- Other Ops Vehicle
- Staff Car
- Lease Car
- Hire Car
- Other
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Please describe other vehicle type
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Manoeuvre in progress at time of Accident.
- Reversing
- Turning Right
- Turning Left
- U Turn
- Going Ahead
- Going Ahead - Right Hand Bend
- Going Ahead - Left Hand Bend
- Overtaking a moving vehicle
- Overtaking Stationary Vehicle(s)
- Other
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Describe Manoeuvre in progress at time of Incident.
DETAILS OF ACCIDENT
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Please give a factual account of the circumstances surrounding and leading to the accident, any conversations which took place.
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Please state who you feel is responsible for the Incident
DECLERATION BY DRIVER
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I declare that the information I have given is correct to the best of my knowledge and belief. SIGN and then PRINT
