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Vehicle Accident Report
Vehicle Accident Report
GENERAL INFORMATION
Report By
*
E-Mail Address
Report Date
*
Accident Date
*
Time Accident
*
12
1
2
3
4
5
6
7
8
9
10
11
:
00
15
30
45
AM
PM
Time Zone
*
N/A
Eastern
Central
Mountain
Pacific
Superintendent
*
Foreman
*
Project Manager
*
Project Number
*
Location
*
Accident location.
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
County Parish
*
Division
*
N/A
Facilities
Main Line
West Texas
Involvement
*
N/A
Caused By
Involved In
Contributed
Witnessed Accident
Report to Agency
*
Yes
No
Agency Contact
*
Location Identifier
*
N/A
Public / Private Road
Right of Way
Facility
Citations Issued
*
Yes
No
To Whom
*
List Violations
*
Type of Collision
*
N/A
Head On
Side Impact
Side Swipe
Rear End
Roll Over
Describe the Accident in Detail
*
N/A
Attachments
Drop a file here or click to upload
Choose File
Maximum file size: 516MB
Documents, pictures, drawings, etc.
COMPANY VEHICLE INFORMATION
Do you need to enter Company Vehicle Information?
*
No
Yes
License Plate
*
License Plate State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Color
N/A
Aluminum
Beige
Black
Blue
Brown
Bronze
Copper
Cream
Gold
Gray
Green
Maroon
Metallic
Navy
Orange
Pink
Purple
Red
Rose
Silver
Turquoise
White
Yellow
Odometer Reading
Vehicle Number
*
Year
Make
*
Model
*
Vin Number
*
Describe Damage To Vehicle
*
COMPANY DRIVER INFORMATION
Do you need to enter Company Driver Information?
*
No
Yes
Drivers Name
*
Driver Behavior Points
0
1-10
11-20
21-30
31-40
41-50
51-90
N/A
Telephone
*
Social Security Number
Date of Birth
Address
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
License Number
*
Time – Present Job
*
N/A
1-6 Mos
6-12 Mos
1-2 Yrs
2-3 Yrs
3-5 Yrs
5-7 Yrs
7-9 Yrs
9-15 Yrs
15+ Yrs
Time – Pipeline Industry
*
N/A
1-6 Mos
6-12 Mos
1-2 Yrs
2-3 Yrs
3-5 Yrs
5-7 Yrs
7-9 Yrs
9-15 Yrs
15+ Yrs
Time – Present Occupation
*
N/A
1-6 Mos
6-12 Mos
1-2 Yrs
2-3 Yrs
3-5 Yrs
5-7 Yrs
7-9 Yrs
9-15 Yrs
15+ Yrs
List Passengers / Witnesses Contact Information
*
N/A
OTHER VEHICLE / PROPERTY
Do you need to enter Other Vehicle / Property details?
*
No
Yes
Year
Make
*
Model
*
Vin Number
*
License Plate
*
License Plate State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Drivers Name
*
Drivers Address
*
Drivers Telephone Number
*
Owners Name
Owners Address
Owners Telephone Number
Describe Damage to Vehicle / Property
*
MEDICAL INFORMATION
Do you need to enter Medical Information?
*
No
Yes
Treatment Facility
*
N/A
Hospital
Emergency Room
Occupational Clinic
Date of First Treatment
*
Contact Information
*
Who Required Off-Site Treatment
*
N/A
INVESTIGATION
Do you need to enter Investigation details?
*
No
Yes
Root Cause Analysis
*
N/A
Yes
No
Type of Analysis
*
N/A
Five Why
Fishbone
Other
Define Other
*
Analysis Team
*
Cause(s)
*
N/A
Contributing Factors
*
N/A
CORRECTIVE ACTIONS
Do you need to enter Corrective Actions?
*
No
Yes
Actions Already Taken
*
N/A
Describe actions taken immediately upon notice of incident
Actions Still To Be Taken
*
N/A
Describe Actions take will be taken at a later date
Projected Date of Completing Actions
*
Date actions that have not be completed will be completed
Person Ensuring Completion of Actions
*
OFFICE USE ONLY
Completed by Safety Management
Approved By
*
Submit
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