Title Page

  • Incident Title

  • Company

  • Conducted on

  • Manager Completing this Form

  • Drivers Name

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?

  • What was the time of the incident?

Location

  • Location of the incident?
  • Type of road

  • Road Junction Type

  • Road Condition

  • Weather Conditions

  • Speed Limit

  • Traffic Density?

Approach

  • Was the driver wearing a seat belt?

  • What lights were switched on?

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

  • Vehicle speed?

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

Actions

  • Own signalling?

  • Other drivers signalling?

  • Horn use

  • Braking?

  • Brake lights on other vehicles?

  • Where did the driver look before performing the manoeuvre?

  • Which mirrors did the driver check?

  • Was the driver using a hand held phone?

  • Was the driver using a hands free phone?

  • Was the driver looking at the sat nav?

  • Any other distractions?

Post Collision

  • Was the employee injured?

  • Was anyone else injured?

  • Details of damage to the company vehicle?

  • Details of damage to the third party vehicle?

  • Does the driver wear glasses?

  • Was the driver wearing glasses?

  • When did the driver last have an eyesight test?

  • Did the driver record witness details?

  • Did the driver take photographs?

  • Did the driver make a sketch of the scene?

  • Were there any passengers in own vehicle?

  • How many were there?

  • Were there any passengers in the other vehicle?

  • How many were there?

  • Were there any injuries?

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

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

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

Reporting

  • Was the MV accident form completed?

  • Was photo of completed accident reporting form sent to Transport & FOM?

  • Was the incident reported to the transport department?

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

  • Was bump card given to other vehicle?

  • Date reported to the transport department?

  • Was the incident reported to the insurers?

  • Were photos taken and sent to Transport & FOM?

  • Date reported to the Insurers?

Signature

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

  • Was this form completed via a phone call with the engineer?

  • Employee Signature if Present

  • Managers Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.