Vehicle Incident Investigation Report

• Site Name

• Date

  Date

• Simpro Job Number

• Location
  Address

• Fantail Employee Name

• Fantail Employee Contact Number

• Fantail Employee Signature

  Sign

• Site Contact Person:

• Site Contact Number:

• Fantail H & S Representative: Erik Potgieter

• Fantail H & S Contact Number: 021 249 3563

• Incident Title

• Division

• Document Number

Vehicle Details

• Make and Model of Vehicle

• Vehicle Registration Number

Times

• What time did the driver start work?

• What time did the journey start ?

• What breaks did the driver taken?

• Was the employee driving their normal vehicle?

  Yes

  No

• What was the time of the incident?

Location

• Location of the incident?
  Address

• Type of road

  Select A Road B Road Single Track Dual Carrageway Motorway Rural Urban

  • A Road
  • B Road
  • Single Track
  • Dual Carrageway
  • Motorway
  • Rural
  • Urban

• Road Junction Type

  Left Turn

  Right Turn

  T Junction

  Roundabout

  Straight Road

• Road Conditions

  Select Good Dry Wet Muddy Snow Ice

  • Good
  • Dry
  • Wet
  • Muddy
  • Snow
  • Ice

• Weather Conditions

  Dry

  Raining Light

  Raining Heavy

  Hale Stone

  Snowing

• Speed Limit

  Select 20km/h 30km/h 40km/h 50km/h 60km/h 70km/h 80km/h 90km/h 100km/h 110km/h

  • 20km/h
  • 30km/h
  • 40km/h
  • 50km/h
  • 60km/h
  • 70km/h
  • 80km/h
  • 90km/h
  • 100km/h
  • 110km/h

• Traffic Density?

  Light Traffic

  Heavy Traffic

  Congested Traffic

Approach

• Was the driver wearing a seat belt?

  Yes

  No

  N/A

• What lights were switched on?

  No lights on

  All lights on

  Side lights on

• Did the driver have a clear view through the windscreen?

  Yes

  No

  N/A

• Vehicle speed?

• How far was the driver behind the vehicle in front?

Actions

• Own signalling?

  Select Left Right None

  • Left
  • Right
  • None

• Other drivers signalling?

  Select Left Right None

  • Left
  • Right
  • None

• Horn use

  No

  Yes

• Braking?

  Yes

  No

• Brake lights on other vehicles?

  Yes

  No

• Where did the driver look before performing the manoeuvre?

  Left

  Right

  Straight Ahead

• Which mirrors did the driver check?

  Driver Side

  Passenger Side

  Rear View

• Was the driver using a hand held phone?

  No

  Yes

• Was the driver using a hands free phone?

  No

  Yes

• Was the driver looking at the GPS System?

  No

  Yes

• Any other distractions?

  Select Eating Drinking CD Radio Map None

  • Eating
  • Drinking
  • CD
  • Radio
  • Map
  • None

Post Collision

• Was the employee injured?

  No

  Yes

• Was anyone else injured?

  No

  Yes

• Details of damage to the company vehicle?

  Driver side impact

  Passenger side impact

  Rear impact

  Front impact

• Details of damage to the third party vehicle?

  Driver side impact

  Passenger side impact

  Rear impact

  Front impact

• Does the driver wear glasses?

  Yes

  No

• Was the driver wearing glasses?

  Yes

  No

• When did the driver last have an eyesight test?

  Last 6 months

  6 to 12 months

  Over 1 year ago

• Did the driver record witness details?

  Yes

  No

• Did the driver take photographs?

  Yes

  No

• Did the driver make a sketch of the scene?

  Yes

  No

• Were there any passengers in own vehicle?

  Yes

  No

• How many were there?

  1

  2

  3

  4

• Were there any passengers in the other vehicle?

  No

  Yes

• How many were there?

  1

  2

  3

  4

• Were there any injuries?

  No

  Yes

• Who's fault did the driver think it was?

  Own Fault

  Third Party Fault

• Is the driver aware of any policies relevant to the incident?

  Yes

  No

• Is there anything the driver could have done to avoid the incident?

  No

  Yes

Reporting

• Was the incident reported to the New Zealand Police?

  Yes

  No

• Was the completed accident reporting form provided to the New Zealand Police?

  No

  Yes

• Date reported to the New Zealand Police?

  Date

• Was the incident reported to the Insurers?

  Yes

  No

• Date reported to the Insurers?

  Date

• Was the completed accident reporting form provided to Insurance Company?

  No

  Yes

• Was a copy of the accident reporting form given to the third party?

  Yes

  No

• Were any available photos taken and sent to the New Zealand Police and the Insurance Company?

  Yes

  No

Signature

• Ask the employee to sign the document on which you have recorded the interview and explain the significance of this decaleration.

• Employee Signature if Present

  Sign

• Managers Signature

  Sign