Incident Form - Vehicle Accident
Incident Type
Incident Type:
*
@Fault
No @Fault
Incident Date:
*
Incident Time:
Late Report?
Yes
No
Were there injuries involved?
Yes
No
If yes, please make sure an injury form is filled out in addition to this form.
Employee Information
First Name:
*
Last Name:
*
Date of Birth:
*
Employee ID:
Department:
*
Job Title:
*
Involved Employees Contact Number:
Supervisor Name:
*
Other Employees Involved:
No
Yes, Whom:
Drug Screen / BAC Completed:
Yes
No
# of hours worked in 7 days:
# of days worked in a row:
Brandt Driver Vehicle Information
VIN:
License Plate #:
Police Report #:
Other Driver Vehicle Information
Drivers Name:
Driver Contact #:
Driver Drivers License #:
Year, Make, Model:
License Plate #:
Vehicle Identification #:
Please take a picture of the drivers license & the drivers insurance card (attach to form).
EVENT INFORMATION
Was the incident a preventable backing collision?
NA
No
If yes, which Brandt Driver Training Point was not followed below?
Looking into the future
360 Degrees
Eye Movement
Escape Routes
If a preventable collision, which of the Brandt Driver Training Points was not followed? N/A
Looking into the future
360 Degrees
Eye Movement
Escape Routes
Communicate
Back Up Camera Present/ Working:
*
Yes
No
Scene Information
Road Condition:
Weather Condition:
Where did the incident occur? (address/ intersection, etc)
Was the employee distracted by any of the following:
GPS
Unsecured Items
Cell Phone
IPAD
OTHER
What was the involved employee doing before the incident?
Please take a picture of the scene of the accident & damage of the vehicles invovled.
Explain what happened below:
Investigation Questionnaire
Was the employee in a hurry?
Yes
No
Was fatigue an issue?
Yes
No
Employee Statement
Did the employee complete a statement?
Yes
No
If yes, explain in detail what happened below or attach statement to the form when submitted.
Employee Signature:
Clear Signature
Date employee statement was completed:
Investigation Completed By:
Signature of Investigator:
Clear Signature
Witness Statement
Was there a witness?
Yes
No
If yes, attach statement to the form when submitted.
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