Traffic Collision Report - Rev Jan 2014

• Conducted on

  Date
• Location
  Address

• Prepared by

• AMR Personnel involved in incident

Incident Summary

• Incident Location:

• Location Type:

  Yes

  No

  N/A

• Operation / Department

• Incident Date:

  Date

• Date AMR Notified:

  Date

• Reported to SRM by:

• Supervisor Phone:

• Brief Summary:

• Type of Claim:

  3001- Property Damage Only - No injury

  3002- Property Damage with Injuries

  3003- Injury(ies) only, No Property Damage

  3004- Fatality to any party involved

  3005- Other

• Responsible Party:

  Select 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

  • 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

• Number of OV's

• Total Number of OV Occupants:

• Number of OV Parties Injured:

• OV Injury Details:

• Number of OV Fatalities:

• Other IV Occupants:

  Yes, on-board but not injured

  Yes, on-board & at least one injured

  No, other passengers on-board

• OV Damage Level:

  No repairable damage

  Minor damage ($1-1000)

  Moderate damage (1k-10k)

  Significant Damage (10k-25k)

  Major damage (25k+)

• OV Damage Description:

• OV Damage Pictures

  Media

• Number in AMR Vehicle (IV):

• Patient on Board?:

  Yes

  No

  N/A

• Patient Name:

• Run # (if pt on board):

• Total number of IV Injuries:

• AMR Injury Detail:

  Select AMR driver injured Partner injured Both driver and partner injured Multiple AMR employees injured Ride-Along injured w/ crew Ride-Along injured only No AMR injuries reported

  • AMR driver injured
  • Partner injured
  • Both driver and partner injured
  • Multiple AMR employees injured
  • Ride-Along injured w/ crew
  • Ride-Along injured only
  • No AMR injuries reported

• AMR Damage Level:

  No repairable damage

  Minor damage ($1-1000)

  Moderate damage (1k-10k)

  Significant Damage (10k-25k)

  Major damage (25k+)

• IV Damage Description:

• AMR Vehicle Damage:

  Media

• AMR Fender ID Number

• Make / Model / Year

• AMR VIN Number:

• License Plate:

• Witness Information:

• Witness Information:

• Witness Information:

• Witness Information:

  Media

• Law Enforcement:

• Report Done:

  Yes

  No

  N/A

• Case / Incident:

• Report:

  Media

Claimant Detail

• Primary Claimant:

  Select OV driver/vehicle owner OV driver/not vehicle owner OV passenger Other property owner (non-vehicle) AMR patient Pedestrian/bicyclist Other AMR passenger N/A - Only if no other party involved

  • OV driver/vehicle owner
  • OV driver/not vehicle owner
  • OV passenger
  • Other property owner (non-vehicle)
  • AMR patient
  • Pedestrian/bicyclist
  • Other AMR passenger
  • N/A - Only if no other party involved

• 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

  Media

Employee Detail

• AMR Driver Last, First:

• AMR Driver Oracle #

• Drivers Date of Hire:

• AMR Driver SSN:

• AMR DOB:

• AMR EE Drivers License Number:

• AMR Driver Gender:

  Male

  Female

• AMR Drivers Status:

  Full Time

  Part Time

  Seasonal

  Temporary

• Occupation Code:

  Select EMT Paramedic RN VST Supervisor / Admin Mechanic Mobile Health Technician Wheelchair Technician

  • EMT
  • Paramedic
  • RN
  • VST
  • Supervisor / Admin
  • Mechanic
  • Mobile Health Technician
  • Wheelchair Technician

• AMR Partner Last, First

• AMR Partner Oracle #

• Attendant Date of Hire:

• AMR DOB:

• AMR Attendant Gender:

  Male

  Female

• AMR Drivers Status:

  Full Time

  Part Time

  Seasonal

  Temporary

• Occupation Code:

  Select EMT Paramedic RN VST Supervisor / Admin Mechanic Mobile Health Technician Wheelchair Technician

  • EMT
  • Paramedic
  • RN
  • VST
  • Supervisor / Admin
  • Mechanic
  • Mobile Health Technician
  • Wheelchair Technician

Accident Details:

• Accident Type:

  Select IV broadsided OV OV broadsided IV IV and OV hit head-on IV sideswiped OV (includes mirrors) OV sideswiped IV (includes mirrors) IV rear ended OV OV rear ended IV IV was hit/damaged while parked

  • IV broadsided OV
  • OV broadsided IV
  • IV and OV hit head-on
  • IV sideswiped OV (includes mirrors)
  • OV sideswiped IV (includes mirrors)
  • IV rear ended OV
  • OV rear ended IV
  • IV was hit/damaged while parked

• Weather Conditions:

  Select Clear Rain Hail Fog Snow Other-Only is IV was in motion N/A - Only if IV was parked

  • Clear
  • Rain
  • Hail
  • Fog
  • Snow
  • Other-Only is IV was in motion
  • N/A - Only if IV was parked

• Road Conditions:

  Select Clear Pavement Wet Sleeted with hail Snowy and/or icy Muddy Dirt Gravel Sanded pavement

  • Clear Pavement
  • Wet
  • Sleeted with hail
  • Snowy and/or icy
  • Muddy
  • Dirt
  • Gravel
  • Sanded pavement

• AMR Vehicle Path:

  Select 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

  • 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

• AMR Vehicle Status:

  Select Non emergent response Non emergent transport Emergent response Emergent transport Parked at scene In service without call Vehicle OOS Support vehicle/routine driving

  • 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:

  Yes equipped and functioning

  Yes equipped but not working

  No, the AMR vehicle is not equipped.

• Siren Detail:

  Indicated AND in use at impact

  Indicated but NOT in use at impact

  Not indicated and not in use

  Not indicated but used anyway

  N/A - Only if vehicle not so equipped

• Warning Light Detail:

  Indicated AND in use

  Indicated but NOT in use at impact

  Not Indicated and not in use

  Not indicated but used anyway

  N/A only if vehicle not so equipped

• AMR Speed Detail:

  Select 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

  • 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:

  Select 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

  • 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

• AMR Backing Detail:

  Select 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

  • 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

• AMR Seatbelt Detail:

  All IV occupants were belted

  AMR driver NOT belted

  Partner NOT belted

  Both driver and partner unbelted

  N/A only if IV parked

• Vehicle Code:

  All Vehicle Code provisions followed

  Vehicle Code(s) violated

  No Vehicle Code is applicable

  Unknown - Under investigation

• AMR Policy:

  All AMR policies were followed

  AMR policy(ies) violated

  No AMR policy is applicable

  Unknown - Under investigation

• Preventability:

  Preventable - Driver Only

  Preventable - Driver & Partner

  Preventable - Partner only

  Preventable - Under investigation

  Non-Preventable

• Corrective Action:

  Corrective action is needed

  No type of corrective action is needed

  Unknown at this time

• Action Plan-Driver:

  Select Remedial education/training Disciplinary action Performance improvement plan (PIP) Combo of discipline & education/training Other documented corrective action Not applicable Unknown at this time

  • 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:

  Select Remedial education/training Disciplinary action Performance improvement plan (PIP) Combo of discipline & education/training Other documented corrective action Not applicable Unknown at this time

  • 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-Partner:

• ETOH/Drug Test (s):

  Done, negative results

  Done, positive results (attach note with details)

  Expected, results pending

  Not applicable

• Attachments

  Media

• Photos of Overall Scene

  Media

• Drawing of Accident Scene

  Drawing

• Driver's Statement

• Driver's Signature

  Sign

• Partner Statement

• Partner Signature

  Sign

• Additional Passenger Statement

• Additional Passenger Signature

  Sign