Employee Accident Reporting Form

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1 License No. ID No.: : Shift Start: Section I Information Accident Reporting Form Disclaimer: The statements in this accident form are provided in anticipation of litigation and are for the sole use of the County of Racine. Incident Date: D.L. State: Section II - Shift and Trip Information Shift End: Origin: Destination: Trip Began: Purpose of Trip: Was there any deviation from direct route? Make: License Plate: Damage: Yes - Explain: No Section III - County Information Model: Yes (Complete Section V) No Accident Occurred While on Overtime: Year: Yes No? Yes No Yes (Complete Section V) No 1

2 ? Yes No License No.: Work Work Make: License Plate and State: Yes (Complete Section V) No Section IV - Other Information / Cell Owner s Information (if different than driver) Model: /Cell is: Owned Leased Yes (Complete Section V) No D.L. State: Year: Privately Owned Rented Damage: Company: Policy Phone Yes (Complete Section V) No Yes (Complete Section V) No 2

3 Section V - Injuries Sex: DOB: Phone In which vehicle: injuries and treatment: Transported by: Fatality Injured Driver Pedestrian Helper Location in vehicle: Transported to: Wearing Seatbelt: Yes No Sex: DOB: Phone In which vehicle: injuries and treatment: Transported by: Fatality Injured Driver Pedestrian Helper Location in vehicle: Transported to: Wearing Seatbelt: Yes No Date of Name of Notified: Location of Accident and Nearest Cross Streets: Weather Conditions at Time of Clear Rain Snow Sleet/Hail Foggy Cloudy Section VI - Accident Information Time of Road Conditions at time of Dry Wet Snow/Slush Date reported: Time supervisor notified: Traffic at Time of Light Moderate Heavy Stopped 3

4 Complete the following diagram to show direction and positions of automobiles or property involved, clearly designating point of contact. Select the street group that best represents the location of your accident or sketch in the available space. Give street names, directions, and locations of objects involved. Indicate location of any traffic control devices. Use the arrows to indicate NORTH. Use solid line to show path before accident And broken line after the accident Number each vehicle; County should be 1, and continuing with each additional vehicle Show railroad by Show motorcycle or bicycle by - Show pedestrian by the accident. Include information regarding the posted speed limit, approximate speed of the vehicles, condition of accident vehicles, traffic controls, lighting conditions, and driver actions and/or statements. Attach additional pages if needed. Section VII - Witnesses Sex: DOB: 4

5 Sex: DOB: Name of Owner: Item Damaged: Owner s Company: Officer Person cited/charged: Section VIII - Property Damage (Other than vehicles) Location of Damaged Item: Tele Policy Estimated Cost: $ Phone Section IX - Police Information Officer Unit No: Report No: Violation(s): Section X - Additional Information (Attach additional pages if necessary) Section XI - Required Attachments: Assignment sheet Location Map Photographs How many: s Written Statement Wisconsin Motor Report or Responding Police Agency s Incident Report Section XII - Signatures Signature: Date: Signature: Date: This form MUST be filled out the day of the incident/accident and submitted to the or Highway Superintendent ASAP. If employee injury(s) does not allow for the form to be filled out the day of the incident/accident, the employee must complete the form immediately upon his or her return to work. 5

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