USSW Vehicle Incident Report V1

• Conducted on

  Date

• Prepared by

• Location

• Weather Conditions

• Injury Claim?

  Yes

  No

  N/A

• Equipment Damage?

  Yes

  No

  N/A

Driver, Passenger and Vehicle Information

• Drivers Name, Address, Drivers License number

• Describe Damage

• Describe Injuries

Third Party Driver, Passenger and Vehicle information

• Driver name, address and Drivers license number of driver

• Passenger name and address (if multiple add all)

• Vehicle make, model and license plate number

• Describe damage to vehicle

• Describe injuries

Employee/ Driver statement

• Location of incident

• Weather conditions

• Date and time of incident

• Driver Statement

Other Driver Statement

• Location of incident

• Date and time of incident

• Other Driver Statement

Witness Statement

• Date and time of incident

• Witness Statement

Lessons Learned/Actions Taken

• What was learned and what corrective action has been taken?

• Yes

  No

  N/A