Page 200 - Personnel Policy and Procedures Manual

FLEET ACCIDENT REPORT (Page 2 of 2)
PRIVATE VEHICLE PASSENGERS EMPLOYEE PASSENGERS

Number of Private Passengers - Name Dept

Number Taken by Ambulance - (list names below) Injured - Yes No Ambulance - Yes
No

Number Injured/No Ambulance -(list names below) Name Dept

INJURIES TO PRIVATE PASSENGERS Injured - Yes No Ambulance - Yes
No

CONDITIONS
Weather -
Clear__Cloudy__Rain__Fog___Snow/Ice__
Road Surface - Dry_____, Wet___,
Gravel___, Sand___, Asphalt___, Dirt ___,
Mud___, Grass___.

FACTORS
Check the Boxes that apply -  Mechanical Failure Present  Driver Error  Excessive Speed
 Alcohol Involved  Drugs Involved  Seatbelts NOT USED

ACCIDENT DESCRIPTION -

All Rights Reserved – As approved by the Commission on 05-07-2019 199 | P a g e