Vehicle Accident Investigation Report Huston

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

Employee Information

• Name of Driver:

• Social Security #:

• Date of Birth:

  Date
• Address of Employee:
  Address

• Employee Phone #:

• Drivers License #:

• Sex:

  Male

  Female

• Date Hired:

  Date

• Employment Status:

  Full Time

  Part Time

  Other

• If other, explain:

• Injurer's Immediate Supervisor:

• Accident Investigated By Whom:

• Accident Date and Time:

  Date

• Person Reported To:

• Date Reported:

  Date

• Time Employee Started Work:

  Date

• Passenger/Witness To Accident:

Vehicle Information

• Huston Vehicle #:

• Vehicle Make:

• Vehicle Model:

• Last 4 of Vin:

• License Plate #:

• Any Damage to Vehicle:

  Yes

  No

Accident Information:

• Address of Accident:
  Address

• Was Any Property Damaged:

  Yes

  No

  N/A

• If yes, property owner name:

• Property Owner Phone #:

• Property Owner Address:
  Address

• Was Another Vehicle Involved:

  Yes

  No

  N/A

• If yes, driver name:

• If yes, driver phone #:

• If yes, driver address:
  Address

• Does other vehicle have damage:

  Yes

  No

• Make and Model of Vehicle:

• Name of Drivers Insurance Company:

• Insurance Company Phone #:

• Did either vehicle need towed?

  Yes

  No

  Both

• If yes, towing company name:

• Towing company phone #:

• Will repairs be needed:

  Yes

  No

  Other

• If yes, name of auto shop:

• Address of auto shop:
  Address

• Were police/emergency crews on scene:

  Yes

  No

  Other

• If yes, officer name:

• Police claim/report #:

• Did anyone need emergency medical services:

  Yes

  No

  Other

• If yes, explain:

• Were seat belts worn at time of accident:

  Yes

  No

• Describe Accident:

Injury Information:

• Injury factor:

  Select Inclement Weather Excessive Speed Vehicle Malfunction Distractions Other

  • Inclement Weather
  • Excessive Speed
  • Vehicle Malfunction
  • Distractions
  • Other

• Body part injured:

  Select Ankle Arm Back Ear Eye Face Finger Foot Hand Forehead Head Hip Knee Leg Mouth Nose Ribs Shoulder Teeth Toe Thumb Wrist Other N/A

  • Ankle
  • Arm
  • Back
  • Ear
  • Eye
  • Face
  • Finger
  • Foot
  • Hand
  • Forehead
  • Head
  • Hip
  • Knee
  • Leg
  • Mouth
  • Nose
  • Ribs
  • Shoulder
  • Teeth
  • Toe
  • Thumb
  • Wrist
  • Other
  • N/A

• Indicate Left or Right:

• Type of Injury:

  Select Abrasion Burn Bruise/Contusion Cut/Laceration Dislocation Fracture Foreign Body Irritation Poisoning Sprain/Strain Other N/A

  • Abrasion
  • Burn
  • Bruise/Contusion
  • Cut/Laceration
  • Dislocation
  • Fracture
  • Foreign Body
  • Irritation
  • Poisoning
  • Sprain/Strain
  • Other
  • N/A

• Could this accident have been prevented:

  Yes

  No

• If yes, how:

Finalization:

• Report Prepared By:

• Signature:

  Sign

• Title:

  Safety Director

  Supervisor

  Foreman

  Other

• Date:

  Date

• Report Reviewed By:

• Signature:

  Sign

• Title:

  Safety Director

  Supervisor

  Foreman

  Other

• Date:

  Date