MOTOR VEHICLE COLLISION REPORT

• Revision Level

• Author

• Date

  Date

• Document No.

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• Employees shall use this form to report all work-related first aid, medical aids, fire, property damage, or near misses. Submit this form to your direct supervisor for further action.

• Type of Report

  Select

• Your Name

• Department

• Supervisor

• Has your supervisor been informed of the incident?

  Yes

  No

  N/A

• Date/Time

  Date
• Location
  Address

Motor Vehicle Collision

• Use your own words to describe the incident.

• Part of Body Affected (Circle all that Apply)

  Drawing

• Location of Injury (Check all that Apply)

  Select

• Type of Injury (Check all that Apply)

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• Motor Vehicle Collision - Describe the visible damage to the vehicle as best as you can. (Supply Pictures)

Motor Vehicle Accidents Only

• Was the vehicle towed from the scene?

  Yes

  No

  N/A

• What garage/address/city/state

• Were the police called to the scene?

  Yes

  No

  N/A

• What city/town/state police

• Were any citations issued to you?

  Yes

  No

  N/A

• Please provide a copy to your supervisor

• Was a police report filed?

  Yes

  No

  N/A

• Please provide copy to your supervisor

• Were you transported by an ambulance to the hospital?

  Yes

  No

  N/A

• Fill out Medical Information Portion Below

• Were you seen by a doctor about this incident?

  Yes

  No

  N/A

• Name and Phone Number of Treating Physician

• Date and Time of Appointment

  Date

• Employee Name

• Employee Signature

  Sign

• Date

  Date