Information

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Incident Summary

  • Incident Location:

  • Location Type:

  • Operation / Department

  • Incident Date:

  • Date AMR Notified:

  • Reported to SRM by:

  • Supervisor Phone:

  • Brief Summary:

  • Type of Claim:

  • Responsible Party:

  • Number of OV's

  • Total Number of OV Occupants:

  • Number of OV Parties Injured:

  • OV Injury Details:

  • Number of OV Fatalities:

  • OV Damage Level:

  • OV Damage Description:

  • OV Damage Pictures

  • Number in AMR Vehicle (IV):

  • Patient on Board?:

  • Patient Name:

  • Incident Number:

  • Total number of IV Injuries:

  • AMR Injury Detail:

  • AMR Damage Level:

  • IV Damage Description:

  • Other IV Occupants:

  • AMR Fender ID Number

  • Make / Model / Year

  • AMR VIN Number:

  • License Plate:

  • AMR Vehicle Damage:

  • Witness Information:

  • Witness Information:

  • Witness Information:

  • Witness Information:

  • Law Enforcement:

  • Report Done:

  • Case / Incident:

  • Report:

Claimant Detail

  • Primary Claimant:

  • Claimant First Name:

  • Last Name:

  • Claimant Address:

  • Claimant City:

  • Claimant State:

  • Claimant Zip Code:

  • Claimant Telephone:

  • Claimant Drivers License Number:

  • Claimant DL State:

  • Claimant DOB:

  • Insurance

  • Insurance Phone:

  • Insurance Policy Number:

  • OV Make / Model / Year:

  • OV License Plate:

  • DL / Registration / Insurance

Employee Detail

  • AMR Driver Last, First:

  • Drivers Date of Hire:

  • AMR Driver SSN:

  • AMR DOB:

  • AMR EE Drivers License Number:

  • AMR Driver Gender:

  • AMR Drivers Status:

  • Occupation Code:

  • AMR Partner Last, First

  • Attendant Date of Hire:

  • AMR DOB:

  • AMR Attendant Gender:

  • AMR Drivers Status:

  • Occupation Code:

Accident Details

Accident Details:

  • Accident Type:

  • Weather Conditions:

  • Road Conditions:

  • AMR Vehicle Path:

  • AMR Vehicle Status:

  • Vehicle Monitoring:

  • Siren Detail:

  • Warning Light Detail:

  • AMR Speed Detail:

  • Intersection Detail:

  • AMR Backing Detail:

  • AMR Seatbelt Detail:

  • Vehicle Code:

  • AMR Policy:

  • Preventability:

  • Corrective Action:

  • Action Plan-Driver:

  • Date Completed-Driver:

  • Action Plan-Partner:

  • Date Completed-Partner:

  • ETOH/Drug Test (s):

  • Attachments

  • Scene Photos

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.