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Driver's Statement

THIS REPORT MUST BE RECEIVED BY SECURITY
SAME DAY AS THE INCIDENT
PROVIDE ALL DETAILS REQUESTED BELOW, INCLUDE DIAGRAM
(LOCATION OF INCIDENT)

TO BE COMPLETED BY SECURITY

CASE # :

VEHICLE DAMAGE REPORT
NON-INJURY REPORT
INJURY REPORT

DRIVERS NAME AND EMPLOYEE #


DRIVERS ADDRESS


DRIVERS LICENSE NUMBER

CLASS D/L    A    B    C    D   RESTRICTIONS

MAKE / MODEL / YEAR VEHICLE YOU WERE DRIVING


VEHICLE PO#


WORK CENTER #


TIME OF INCIDENT


DATE OF INCIDENT


LOCATION OF INCIDENT


WHO WAS NOTIFIED IN OFFICE(SUPERVISOR)


WHEN WAS SECURITY NOTIFIED?

DATE
TIME

REPORTING OFFICER

WAS ANYONE HURT?    YES    NO   

NAME(S)


ADDRESS


PHONE


IF YES, EXPLAIN IN DETAIL:


WERE PARAMEDICS CALLED:


WHAT ASSISTANCE WAS GIVEN TO INJURED:


WHO PROVIDED ASSISTANCE:


DID INJURED REMAIN AT THE SCENE:


WAS INJURED TRANSPORTED VIA AMBULANCE:


RELEASED TO:


OTHER:


NAME OF WITNESSES


ADDRESS


PHONE NUMBER


VEHICLE USE AT TIME OF INCIDENT / HOW FAR AWAY WAS OTHER VEHICLE WHEN NOTICED


IF FAULTY CONDITION OF EITHER VEHICLE CAUSED INCIDENT, EXPLAIN:


COMPLETE DIAGRAM INDICATING STREETS & DIRECTIONS & COURSE OF EACH VEHICLE ALSO POSITIONS AT TIME OF IMPACT


PLEASE DESCRIBE INCIDENT IN DETAIL, STATING WHAT YOU KNOW ABOUT THE INCIDENT, COMMENT UPON ANY STATEMENTS MADE BY YOURSELF OR OTHERS AT THE SCENE OF THE INCIDENT. IF UNSURE HOW DAMAGE OCCURRED STATE WHAT YOU KNOW ABOUT THE DAMAGE, INCLUDING POSSIBLE CAUSE, INCLUDE THE FOLLOWING DETAILS (FOR ALL VEHICLES), SPEED, LOCATION, DIRECTION, DESCRIBE CONDITION OF WEATHER, ROAD TRAFFIC CONDITIONS AND VISIBILITY.