Title Page
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Incident Title
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Company
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Conducted on
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Manager Completing this Form
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Drivers Name
Vehicle Details
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Make and Model of Vehicle
- Mercedes Benz Vito
- Mercedes Benz Sprinter
- Volkswagen Caddy
- Volkswagen Passat
- Volkswagen Golf
- Audi A3
- Audi A4
- Audi A5
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Vehicle Registration Number
Times
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What time did the driver start work?
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What time did the journey start ?
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What breaks did the driver taken?
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Was the employee driving their normal vehicle?
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What was the time of the incident?
Location
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Location of the incident?
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Type of road
- A Road
- B Road
- Single Track
- Dual Carrageway
- Motorway
- Rural
- Urban
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Road Junction Type
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Road Condition
- Good
- Dry
- Wet
- Muddy
- Snow
- Ice
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Weather Conditions
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Speed Limit
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Traffic Density?
Approach
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Was the driver wearing a seat belt?
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What lights were switched on?
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Did the driver have a clear view through the windscreen?
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Vehicle speed?
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How far was the driver behind the vehicle in front?
Actions
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Own signalling?
- Left
- Right
- None
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Other drivers signalling?
- Left
- Right
- None
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Horn use
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Braking?
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Brake lights on other vehicles?
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Where did the driver look before performing the manoeuvre?
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Which mirrors did the driver check?
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Was the driver using a hand held phone?
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Was the driver using a hands free phone?
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Was the driver looking at the sat nav?
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Any other distractions?
- Eating
- Drinking
- CD
- Radio
- Map
- None
Post Collision
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Was the employee injured?
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Was anyone else injured?
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Details of damage to the company vehicle?
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Details of damage to the third party vehicle?
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Does the driver wear glasses?
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Was the driver wearing glasses?
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When did the driver last have an eyesight test?
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Did the driver record witness details?
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Did the driver take photographs?
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Did the driver make a sketch of the scene?
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Were there any passengers in own vehicle?
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How many were there?
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Were there any passengers in the other vehicle?
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How many were there?
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Were there any injuries?
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Who's fault did the driver think it was?
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Is the driver aware of any policies relevant to the incident?
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Is there anything the driver could have done to avoid the incident?
Reporting
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Was the MV accident form completed?
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Was photo of completed accident reporting form sent to Transport & FOM?
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Was the incident reported to the transport department?
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Was a copy of the MV accident form given to the third party?
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Was bump card given to other vehicle?
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Date reported to the transport department?
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Was the incident reported to the insurers?
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Were photos taken and sent to Transport & FOM?
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Date reported to the Insurers?
Signature
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Ask the employee to sign the document on which you have recorded the interview and explain the significance of this decaleration.
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Was this form completed via a phone call with the engineer?
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Employee Signature if Present
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Managers Signature