Late Accident Report Form Page 2
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1
2PLEASE DRAW A DIAGRAM OF WHAT HAPPENED
(be sure to include all vehicle, pedestrian and bicyclist maneuvers both prior and after the collision)
Number of each vehicle as it appears on the front of this report. Indicate the direction each was traveling by an arrow.
Draw an arrow here
Include all objects involved (e.g. buildings, bridges, poles, fences, or guard ports, etc.)
pointing North (
)
DIRECTION OF TRAVEL OF EACH VEHICLE, PEDESTRIAN, ETC.
N
S
E
W
Vehicle #1 going
(
)
(
) (
) (
)
on__________________________________________________________________________________
N
S
E
W
Vehicle #2 going
(
)
(
)
(
) (
)
on___________________________________________________________________________________
NARRATIVE - DESCRIBE EVENTS AS TO HOW COLLISION OCCURRED
(D) WEATHER CONDITIONS (check one)
(E) ROAD SURFACE (check one)
(F) LIGHT CONDITIONS (check one)
1 Clear___
6 Sleet or
1 Dry ____
6
Muddy _____
1
Daylight _____
2 Raining _____
Freezing Rain _____
2 Wet ____
7
Freshly Oiled _____
2
Dawn _____
3 Fog ____
7 Cloudy _____
3 Icy _____
8
Loose Sand _____
3
Dusk _____
4 Rain and Fog____
8 Other (specify)
4 Snowy _____
9 Other(specify)
4
Darkness, no highway illumination_____
5 Snowing ____
________________
5 Slushy _____
___________________
5
Darkness, with highway illumination_____
I declare under penalties provided by law this report has been examined by me and to the best of my knowledge the
information contained herein is true and correct.
PLEASE SIGN HERE_____________________________________________ DATE _________________
W ritten signature of operator submitting this report must be the same as that of Operator #1 on the face of this report.
Signature must be signed in ink.
GPD 30
REV 10/99
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