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| Annual MVR & Safety review (Date, With whom) | ||||
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| Employee's Manager Workgroup Safety History in last 12 months. | ||||
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| Root Cause #1 | ||||
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JPG or PNG
VEHICLE ACCIDENT REPORT
Try to Calm Yourself and Breath Slowly-Vehicle #1 is you
1. Are you injured?
Yes
Degree of Injury
N/A
Call 911 if injury requires immediate attentionDegree of Accident
Major
2. Is the accident location secured?
Yes
- DO NOT PLACE YOURSELF OR OTHERS IN HARMS WAY!!!
- If possible, take as much video or pictures of the scene as possible if it is safe to do so
- If not, attempt to secure scene if it's safe to do so
- If absolutely necessary, move vehicle to a safe location within reason
NEVER ATTEMPT TO MOVE ANYONE UNLESS THEY ARE IMMINENT DANGER
3. Is anyone else injured?
Yes
Number of injuries
N/A
Degree of injury
1
Is anyone being Transported?
0
4. Is there any Fatalities?
Yes
5. Are there Emergency Personnel on site?
Fire
Yes
Police
Yes
Paramedics
Yes
Coroner
Yes
6. Is there a fire?
Yes
Size of Fire
Yes
Fire Extinguisher available
Yes
Fire Extinguisher used
Yes
7. Is there a Spill?
Yes
Size of Spill
Yes
Type of Spill
Yes
Is the Spill contained
Yes
8. Is there another vehicle involved?
Yes
# of other vehicles
Yes
9. Does the your vehicle need to be towed
Yes
Do any other vehivle need to be towed
Yes
# of vehicles towed
Yes
Be prepare to provide REQUIRED documents (Insurance, Registration, Phone #, License[Name, Lic #, Address])
NEVER admit Guilt-NEVER apologize-Only review what happened-You only have to speak to the authorities
Gather Information
Photos
Address or Location of Accident and Conditions
| Address or Location | Interstate 605 North past the Slauson Exit |
Witnesses
| Record Id | First Name | Last Name | Driver License Number | Home Phone Number | Work Phone Number | Mobile Phone Number | Actions |
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| Record Id | Driver First Name | Driver Last Name | Driver License Number | Driver License State | Driver License Expiration Date | Driver Address | Driver City | Driver State | Driver Zipcode | Actions |
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| Record Id | Trailer Make | Trailer Size | Registration Current | Inspection Current | License Plate Number | License State | Dolly Type | Actions |
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