Fillable OPERATOR'S REPORT OF ACCIDENT Page 1 of 2 (Ottawa Student Transportation Authority)

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OPERATOR'S REPORT OF ACCIDENT Page 1 of 2 (Ottawa Student Transportation Authority)

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Country of origin: CANADA
File type: PDF

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OPERATOR'S REPORT OF ACCIDENT Page 1 of 2
DATE / TIME INFORMATION
Does this claim involve any bodily injury? Were there passengers on board?
Date of Accident: / / Day of the Week: Time of Day:
DD / MM / YY
BUS OPERATOR / DRIVER Driver:
Company: Driver ID #: Age: Date of Hire:
Street: Street:
City: City: Province:
Province: Postal Code: Postal Code: Phone #: ( )
Phone #: ( ) Fax: ( ) License #:
Acting Manager: Expiry Date: Class:
POLICE ENFORCEMENT
Police Attended? Police Report?
TYPE OF VEHICLE
ESTIMATED DAMAGE:
$
Please circle damaged areas (1-10)
Route #: Capacity: Vehicle #: 9 Top 2 3 4
Year: Make: 10 Under 1 5
Model: License Plate: 6 7 8
LOCATION OF ACCIDENT Brief Description of Damages:
Street:
City: Province:
Intersection of:
Location details:
THIRD PARTY INFORMATION
Name of Driver: Phone #: ( )
Street Address: City: Prov: Postal Code:
Vehicle Details: Make / Model: Year: License Plate:
Insurance Co.: Agent Name:
Street: City: Prov: Postal Code:
Policy #:
Cited: Driveable: Total Loss:
Driver of 2nd Vehicle: Phone #: ( )
Street: City: Province: Postal Code:
INJURED'S NAME AND ADDRESS TELEPHONE NUMBER AGE EXTENT OF INJURY
1. ( )
2. ( )
3. ( )
WITNESS NAME AND ADDRESS TELEPHONE NUMBER AGE LOCATION OF WITNESS
1. ( )
2. ( )
3. ( )
YES NO
a.m.
p.m.
YES NO YES (ATTACH COPY) NO
SCHOOL BUS VAN OTHER:
NO
Y
ES NO
Y
ES
Y
ES NO
YES NO
CLEAR FORM
OPERATOR'S REPORT OF ACCIDENT Page 2 of 2
Route #: # of Passengers: Please ensure a passenger name list is attached to this report.
DIAGRAM OF ACCIDENT (Diagram to be completed by the driver)
WEATHER CONDITIONS (check)
NOTE:
ROAD CONDITIONS (check)
NOTE:
LIGHT CONDITIONS (check)
vehicle is ALWAYS number 1
NOTE:
EMPLOYEE / DRIVER DESCRIPTION OF ACCIDENT: Posted speed limit: kph
Travelling speed: kph
Vehicle lights on?
Employee / Driver Signature: Date:
ROAD CONTOUR (check) OCCURRENCE (check)
TWO VEHICLE COLLISION (check) ONE VEHICLE COLLISION (check)
ALLEGED EMPLOYEE / DRIVER ERROR (check)
RESULT OF OPERATOR INVESTIGATION / ACTION TAKEN
Operator Authorized Signature: Date:
Right Left
1. No adverse conditions
2. Rain
3. Snow
4. Fog
5. High Wind
1. Dry
2. Wet
3. Snow
4. Ice
5. Dirt
6. Sand
1. Daylight
2. Dawn
3. Dusk
4. Dark
5. Dark-lighted
6. Other
1. Straight Level
2. Straight Grade
3. Curve Level
4. Curve Grade
1. On Roadway
2. Off Left Side
3. Off Right Side
4. On Opposing Lane
1. Backing
2. Rear End
3. Head On
4. Intersection
5. Turning
6. Other:
1. Backing
2. Hit Fixed Object
3. Parked Vehicle
4. Pedestrian
5. Other:
1. Turns
2. Intersections
3. Sideswipe
4. Backing
5. Rear ended other vehicle
6. Rear ended by another vehicle
7. Lane change
8. Pedestrian
9. Collision with stationary object
10. Overhead objects
11. Miscellaneous
12. Not Applicable
SCHOOL NOTIFIED OSTA OFFICIALS NOTIFIED OTHER: _______________________
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OPERATOR'S REPORT OF ACCIDENT Page 1 of 2 (Ottawa Student Transportation Authority)

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Completed 28 May 2021

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