5. WAS ANYONE INJURED, AND IF SO, EXTENT OF INJURY IF KNOWN?
STATEMENT OF WITNESS
(Attach additional sheets if necessary)
OMB Control Number: 3090-0118
Expiration Date: 8/31/2020
STANDARD FORM 94 (REV. 3/2017)
Prescribed by GSA-FMR (41 CFR) 102-34
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork
Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The
OMB control number for this collection is 3090-0118. We estimate that it will take 20 minutes to read the instructions, gather the facts, and answer the
questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of
information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.
c. E-MAIL ADDRESS
b. HOME ADDRESS (Include ZIP Code)
a. NAME OF WITNESS:
1. WITNESS INFORMATION
f. HOME TELEPHONE NUMBER
e. CELLULAR TELEPHONE NUMBER
d. WORK TELEPHONE NUMBER
p.m.
a.m.
d. TIME YOU ARRIVED AT SCENE?
a. DID YOU WITNESS THE ACCIDENT?
2. ACCIDENT INFORMATION
6. DESCRIBE THE APPARENT DAMAGE TO PRIVATE PROPERTY.
4. TELL IN YOUR OWN WAY HOW THE ACCIDENT HAPPENED.
3. WHERE DID THE ACCIDENT OCCUR? (Give Street Location, City, and State)
9. DID YOU NOTICE ANYTHING UNUSUAL PRIOR TO OR DURING THE ACCIDENT?
IF YES, PLEASE DESCRIBE WHAT YOU NOTICED AND WHY YOU THINK IT WAS PERTINENT TO THIS ACCIDENT.
8. DESCRIBE ROAD AND CONDITIONS THAT INFLUENCED THE ACCIDENT (e.g. weather, terrain, debris, road work, time of day).
7. DESCRIBE THE APPARENT DAMAGE TO GOVERNMENT PROPERTY.
b. DATE OF ACCIDENT:
c. TIME OF ACCIDENT:
p.m.
a.m.
