Road Traffic Accident Report Form

• Incident summary

• Date of investigation

  Date

• Prepared by

• Location
  Address

• Personnel

Essential details

• Select the date and time of the incident

  Date

• Enter the road name including nearest junction details

• Select the weather conditions

  Select Sunny Partially Sunny Overcast Rain Windy Foggy

  • Sunny
  • Partially Sunny
  • Overcast
  • Rain
  • Windy
  • Foggy

• Night time?

  Off

  On

Summary of the accident

• undefined

Accident plans

• Add photos of the position of the vehicles at the time of the accident

  Media

• Select the approximate speed at the time of impact

• Were there any witnesses to the accident? If so give details including full contact details

  Yes

  No

  N/A

Information given to

• Were Police called? Details of who attended and any reference given

  Yes

  No

  N/A

• To which hospital were the injured parties taken

• Ambulance called? Give details of who attended, call sign etc

  Yes

  No

  N/A

• Fire & Rescue Service called? Record officer in charge or photo of appliance identification

  Yes

  No

  N/A

• Insurance company informed - give reference received

  Yes

  No

  N/A

Impact of Accident

• Personal Injury details

• Vehicle Damage details

Root Cause

• What was the immediate cause of the incident?

• Were there any underlying causes?

Corrective Actions

• Are there any corrective actions required?

  Yes

  No

  N/A

• Detail any corrective actions/follow up required

Ongoing Monitoring

• Does the employee require any on going support?

  Yes

  No

  N/A

• What additional support can the company give the employee?

  Yes

  No

  N/A