Accident incident report form checklist
An accident incident report form is used when someone got injured as a result of collision. this template can be used by fleet managers to document the details of the incident. use this template to guide the inspector to perform the following: 1. capture all contact details and verification information of the injured person 2. describe full details of the injury and the accident 3. take photo evidence of the surroundings 4. record emergency services involvement (i.e. police, fire, paramedics), hospitalization information and witness statements 5. capture electronic signatures from the relevant person involved and injured person
What does this form include?
This form contains 23 sections:
Name of driver
Driver's license number
Car registration number
Identification number
Take photo of ID
Injured Person Background
Date of Birth
Telephone Number
Address Address
Date and time of event Date
What part of the body was injured? Describe in detail
Take photo of the body part that was injured. Annotate as required
Describe fully how the accident happened?
Take photo of the surrounding
Injury Details
- Were safety regulations in place and used?
Witness Statements
- Were there any witnesses?
Enter witness name
Contact number
Witness statement
Witness signature
Emergency Services
- Employee went to doctor/ hospital?
- Police were called to the scene
Injured person (Full Name and Signature)
Fleet manager (Full Name and Signature)
Use this template