VEHICLE ACCIDENT REPORT FORM

• Document No.

• Audit Title

• Client / Site

• Date / Time of Accident

  Date

• Prepared by

• Location
  Address

• Drivers / Employees Name

DRIVERS INFORMATION

• Drivers License Number and State:

• Current Home Address:

• Current Telephone Number:

• Position:

  Select Driver Laborer Foreman Supervisor Manager HSE Other

  • Driver
  • Laborer
  • Foreman
  • Supervisor
  • Manager
  • HSE
  • Other

Vehicle Information:

• Unit Number:

• Year of Vehicle:

• Color:

• VIN Number:

• License Plate Number:

• State:

• Where is vehicle currently:

• Is Vehicle drivable:

  Select YES NO

  • YES
  • NO

TROOPER / OFFICER INFORMATION

• Trooper / Officer Name:

• Badge Number:

• Report Number:

• Department:

  Select Local Police Dept. Sheriff Dept. State

  • Local Police Dept.
  • Sheriff Dept.
  • State

ACCIDENT INFORMATION:

• Any Personal Injuries:

  Select YES NO

  • YES
  • NO

• Name of Injured Party:

• Current Address:

• Current Telephone Number:

• Type Accident:

  Select Property Equipment Vehicle Environmental

  • Property Equipment
  • Vehicle
  • Environmental

• List Equipment Involved:

• Other Vehicle Description:

• Other Vehicle Owner / Driver

• Show a drawing of the accident and give an indication of North:

  Drawing

• Pictures Of Company Vehicle / Equipment

  Media

• Pictures of the other parties vehicle / equipment involved:

  Media

INJURIES:

• Accident Description:

• Weather Conditions;

  Select DRY WET ICE SNOW

  • DRY
  • WET
  • ICE
  • SNOW

• Road Type:

  Select Pavement Dirt Road Off Road

  • Pavement
  • Dirt Road
  • Off Road

• Injuries / Nature of Injuries

• Was First Aid Rendered?

  Select YES NO

  • YES
  • NO

• If yes, by Whom?

• Did Injured leave job?

  Select YES NO

  • YES
  • NO

• If yes, to where? (List Name and Address of Hospital or Clinic if Applicable)

• Was the party involved in the incident / accident Drug and Alcohol Tested?

  Select YES NO

  • YES
  • NO

• If tested, Location of the test:

Witnesses:

• Name of witness working #1 at the time of the Incident / Accident occurred:

• Telephone Number:

• Company Name:

• Name of witness working #2 at the time of the Incident / Accident occurred:

• Telephone Number:

• Company Name:

• Name of witness working #3 at the time of the Incident / Accident occurred:

• Telephone Number:

• Company Name:

Corrective Action Plan:

• Corrective Action:

• Corrective Action Completed By:

• Date:

  Date

• Report Completed By:

  Sign

• Title / Position

  Select HSE MANAGEMENT SUPERVISOR FOREMAN

  • HSE
  • MANAGEMENT
  • SUPERVISOR
  • FOREMAN

• Date:

  Date

• This report must be completed in full by Supervisor whenever an Incident / Accident occurs to include personal injury, vehicle damage, equipment damage, or damage to the environment. Upon completion this report is then forwarded to the H.S.E / Risk Management Department in Berwick, La.