Accident Investigation Form \ Sample 3

Vehicular

Date of the accident ____________________________________

Names of the individual(s) involved ________________________

______________________________________________________

Employment status (i.e., employee or volunteer): _____________

Place of the accident (location, street address/intersection, or any other location description) ____________________________________________

What happened: ________________________________________

______________________________________________________

Vehicles or equipment involved: ___________________________

______________________________________________________

Weather conditions: _____________________________________

Was law enforcement involved? Citation(s) issued? Nature of violation?
______________________________________________________

Injuries:_______________________________________________

Name Injury? Hospitalized? W/C claim?
       
       
       
       
       

Damage to property _____________________________________

Witness Name Address Telephone