Traffic Collision

Information

Conducted on
Location
Prepared by:
W.C. Spratt, Inc. personnel involved in incident:

Incident Summary

Incident Location:
Incident Date:
Incident Type:
Date Safety Manager Notified:
Reported to Safety Manager by:
Supervisor Phone:
Brief Summary:
Location Type:
- Clear Pavement
- Wet
- Sleeted with hail
- Snowy and/or icy
- Muddy
- Dirt
- Gravel
- Sanded pavement
Type of Claim:
Responsible Party:
- IV Potentially at fault/responsible
- OV Potentially at fault/responsible
- Dual IV/OV shared responsibility
- Unknown -Under investigation
- No claimant identified - hit &run
- N/A -only if no other party involved

Vehicle Information

Number of Vehicles
Total Number of Vehicle Occupants:
Number of Vehicle Parties Injured:
Vehicle Injury Details:
Number of Vehicle Fatalities:
Other Vehicle Occupants:
Vehicle Damage Level:
Vehicle Damage Description:
Vehicle Damage Pictures
Drawing of Accident Scene
Vehicle Fender ID Numbers
Vehicle's Make / Model / Year
Vehicle VIN Numbers:
Vehicle License Plates:
Witness Information:
Add signature
Witness Information:
Add signature
Law Enforcement Notified?
Report Done?
Case / Incident:
Report:
Insurance
Insurance Phone:
Insurance Policy Number:
Vehicle Make / Model / Year:
Vehicle License Plate:
DL / Registration / Insurance

Employee Detail

Employee Driver Last, First:
Employee ID Number:
Employee Driver License #
Drivers Date of Hire:
Employee Driver SSN:
Employee DOB:
Employee Drivers Status:

Accident Details

Accident Details:

Accident Type:
- W.C. Spratt, Inc. driver injured
- Partner injured
- Both driver and partner injured
- Multiple AMR employees injured
- Ride-Along injured w/ crew
- Ride-Along injured only
- No W.C. Spratt, Inc. injuries reported
Weather Conditions:
- Clear
- Rain
- Hail
- Fog
- Snow
- Other-Only is IV was in motion
- N/A - Only if IV was parked
Road Conditions:
- Clear Pavement
- Wet
- Sleeted with hail
- Snowy and/or icy
- Muddy
- Dirt
- Gravel
- Sanded pavement
W.C. Spratt, Inc. Vehicle Path:
- Driving in normal traffic direction
- Driving against normal traffic direction
- IV driving on left median
- IV driving on right shoulder
- IV slitting lanes
- Crossing freeway median divide
- Other -Only in motion
- N/A - only if IV was parked
W.C. Spratt, Inc. Vehicle Status:
- Non emergent response
- Non emergent transport
- Emergent response
- Emergent transport
- Parked at scene
- In service without call
- Vehicle OOS
- Support vehicle/routine driving
Vehicle Monitoring:
Siren Detail:
Warning Light Detail:
W.C. Spratt, Inc. Speed Detail:
- IV traveling at posted limit
- IV traveling over posted speed limit
- IV traveling at excessive speed
- IV stopped/near stop at time of impact
- IV was parked
- Unknown-under investigation
Intersection Detail:
- IV had green light / no stop needed
- IV made all required complete stops
- IV rolling stops involved (slowed only)
- Initial stop/no stop at open lanes
- IV made no attempt to slow or stop
- N/A only if no intersection involved
- Unknown- under investigation
W.C. Spratt, Inc.Backing Detail:
- No spotter available/driver alone
- Spotter was with patient in back
- Spotter in right-cab seat
- Non-employee spotter used
- Driver did not follow spotters signals
- Spotter did not give clear signals
- Errors by both driver and spotter
- N/A only is not backing collision
W.C. Spratt, Inc.Seatbelt Detail:
Vehicle Code:
W.C. Spratt, Inc. Policy:
Preventability:
Corrective Action:
Action Plan-Driver:
- Remedial education/training
- Disciplinary action
- Performance improvement plan (PIP)
- Combo of discipline & education/training
- Other documented corrective action
- Not applicable
- Unknown at this time
Date Completed-Driver:
Action Plan-Partner:
- Remedial education/training
- Disciplinary action
- Performance improvement plan (PIP)
- Combo of discipline & education/training
- Other documented corrective action
- Not applicable
- Unknown at this time
Drug Test (s) Performed within (2) hours of Incident:
Attachments