Fillable Vehicle Accident/Incident Report Form

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Vehicle Accident/Incident Report Form

On average this form takes 22 minutes to complete

The Vehicle Accident/Incident Report Form form is 2 pages long and contains:

  • 0 signatures
  • 17 check-boxes
  • 80 other fields

Country of origin: OTHERS
File type: PDF

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Vehicle Accident/Incident Report Form
Salt Lake City Corpora
tion
Employee and Vehicle Information
Driver’s Name (Last, First, MI)
Department
Supervisor
Division
Section
Driver License Number
Employee’s Usual Occupation
Employee Work Number
Job Title
Hire Date
Time in occupation at time of accident
Less than 1 month
1 to 5 months
6 months to 5 years
More than 5 years
Name of Owner (if not City owned)
Owner Address
Owner Phone Number
City Vehicle Damage
Date of Accident
Time of Accident
Hour
Dawn
Day
Dus
k
Night
Accident Location
Hours on Shift
1
2
3
4
5
6
7
8
9
10
Employee Injured?
Yes
No
AM PM
Seatbelt
Used
Not Available
Not Applicable
Available But Not Used
Citation Issued?
Yes, to City Driver
Yes, to Other Driver
No Citation Issued
Type of City Vehicle
Vehicle Description (Year, Make, Model)
City Vehicle Number
License Plate Number
Damage Cost Estimate
$
Vehicle Damage Description
Other Vehicle
Driver’s Name
Driver’s Phone Number
Driver’s Address
Owner’s Name
Owner’s Phone Number
Owner’s Address
Driver License Number
License Plate Number
State
Insurance Company
Policy Number
Vehicle Description (Year, Make, Model)
Insurance Agency Phone Number
Description of Damage
Driving Conditions
What Drivers Were Doing
ROAD CONDITIONS
ROAD SURFACE
TRAFFIC
VEHICLE CONDITION
.
Vehicle No.
Vehicle No.
Vehicle No.
Light
1
2
3
1
2
3
1
2
3
Dry
Concrete
Moderate
Normal
Right Turn
Forward from Parking
Wet
Asphalt
Heavy
Brakes
Left Turn
Backing
Ice/Snow
Gravel
Steering
U-Turn
Backing from Parking
Muddy
Dirt
Headlights
Moving Forward
Stopped in Traffic
Other
Other
Taillights
Slowing/Stopping
Parked
Tires
Passing
Other
Other
This incident categorized as
Accident Damage
Police Case Number
______________________
(Attach additional form(s) if multiple vehicles were involved)
Witnesses
(Names, Addresses, and Telephone Numbers)
Salt Lake City Police Report Number
Investigating Agency
Report Number
Diagram of Accident
INSTRUCTIONS:
1. Show and label streets.
2. Show traffic signs.
3. Add a north arrow to circle above.
4. Show City vehicle with this symbol:
5. Show other vehicles with these symbols:
6. Use solid line to indicate direction travel before collision
7. Use dashed line to indicate direction of travel after collision
Description of What Happened
SUBMITTED BY
SIGNATURE
DATE INVESTIGATED
NUMBER OF
PHOTOS TAKEN
Give copies of this report to your supervisor, Fleet (Box 5542) and Risk Management (Box 5478)
2
3
Indicate North
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Vehicle AccidentIncident Report Form

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Completed 2 June 2021

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