Title Page
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Document No.
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District/Area
- Charlotte
- Kermit
- Monahans
- Orla
- Stockdale
- Nitrogen
- Office
- Crude Long Haul
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Date and time of incident
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Location
Company Driver Information
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Employee's Name
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Occupation
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Contact Phone Number
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Home address
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Supervisor
- Don Shaw
- Earnest Watson
- Edward Johnson
- Jeff Guy
- Jorge Gomez
- Troy Pruitt
- Kurt Grandshire
- Ralph Brunt
- Rudy Espinosa
- Richard Jimenez
- Art Gunn
- Sly Torres
- Mike Yow
- Derrell Hardison
- Ron Brownridge
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Was Driver Injured?
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Was Injury report completed?
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Briefly state nature of injuries
Company Vehicle Information
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Unit Number
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Description of Damage (if not damaged, state accordingly)
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Was the vehicle removed by tow truck?
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Trailer Number (if no trailer, enter N/A)
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Description of Damage (if not damaged, state accordingly)
Hazardous Materials Information
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Was Hazardous Materials spilled/released?
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Run Ticket Number
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Load Origination (enter lease name)
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Load Destination (enter unloading station name)
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Tank volume before spill/release
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Estimated volume lost
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Estimated volume salvaged
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Explain what caused spill/release
Other Vehicles/Parties/Property
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PROPERTY DAMAGE - Describe any property damage and owner information available.
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Was another vehicle involved?
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Owner name (if known)
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Make/Model of vehicle
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Driver's Name
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Insurance Carrier Name, address and phone (if available)
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Insurance Policy #
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Was anyone injured in this vehicle?
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Was another vehicle involved?
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Owner name (if known)
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Make/Model of vehicle
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Driver's Name
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Insurance Carrier Name, address and phone (if available)
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Insurance Policy #
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Was anyone injured in this vehicle?
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Was this vehicle towed from the scene?
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Was another vehicle involved?
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Owner name (if known)
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Make/Model of vehicle
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Driver's Name
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Insurance Carrier Name, address and phone (if available)
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Insurance Policy #
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Was anyone injured in this vehicle?
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Was this vehicle towed from the scene?
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Was another vehicle involved?
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Owner name (if known)
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Make/Model of vehicle
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Driver's Name
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Insurance Carrier Name, address and phone (if available)
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Insurance Policy #
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Was anyone injured in this vehicle?
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Was this vehicle towed from the scene?
Witnesses
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Witness Name, Address and Phone Number
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Witness Name, Address and Phone Number
Injured Parties
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Describe to the best you can any details on injuries sustained by other parties involved in crash.
Police or other Authority
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Officer Name/Badge #
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Agency and phone number
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Was a citation issued
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To whom was the citation issued to?
Details of Crash
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Describe - in detail - the sequence of events that led up to and caused the crash
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Weather Conditions
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Lighting Conditions
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Road surface type
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List any defective equipment, objects, substances, conditions or other parties that may have contributed to this crash
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List other concerns or points of interest
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Was a Root-Cause Analysis conducted? Findings?
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How can this be prevented in the future
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DOT Recordable? (If not known, select unknown and it will be updated at a later time)
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Crash Preventability
Sketch out a site diagram on paper and attach here
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Add media
Add documents, pictures, police reports, inspections or other images.
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Add media
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Add media
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Add media
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Add media
Follow up Action. List any follow up action as a result of this crash. Describe the action item, responsible person and target date.
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Enter any follow up items
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Supervisor Signature
