Incident/accident Report - Within 24 Hours
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1Incident/Accident Report
Report all incidents/accidents within 24 hours.
Driver Name____________________________________________________
1. Date and Time of Incident:
_______
2. Location of Incident:
3. Name and Phone of Rider(s) Involved:
What is a reportable
a.
incident?
b.
motor vehicle accident
c.
receiving a ticket
4. Seat belt in use?
Yes / No
being stopped by a law
enforcement official
5. If a child under age eight, was a car seat or booster seat in
medical emergency
occurring while you are
use? Yes / No
transporting a client
6. Name and Phone Number of Witness(es) to Incident:
any time 9-1-1 is called
while you are driving
a.
an altercation between
b.
clients or between driver
and client
c.
if a driver or client injures
7. Were another agency(s) {i.e. Police, DSS, Fire Dept.}
themselves during a trip
involved? Yes / No
Questions?
Provide the name of the officer and accident report number;
Call your Program
Director
include phone number: ________________________________
Explain the incident in detail: (continue an added sheet if needed)
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
____________________________________________________
____________________
Volunteer Driver Signature
Date
_______________________________________________________________________________________
For Office Use
Received by: __________________
Date received: _______________ Follow up completed: _________________
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Parent category: Business