COUNTY OF EL PASO Vehicle Traffic Accident Report Form Page 1 of 3 PART I (TO BE FILLED OUT BY THE INVOLVED EMPLOYEE) ALL TRAFFIC ACCIDENTS SHALL BE REPORTED WITHIN 48 HOURS TO HUMAN RESOURCES DEPARTMENT MANAGEMENT DIVISION –RISK Employee Name: D.O.B. DL#: Date of Employee Home Address: Hire Job Department: Time of Time Shift Began: Week Day: Date of Accident Accident: Location of Accident: Make: Vehicle Information: Year: Make: Model: VIN# (last 4): Model: VIN# Describe details of the accident. Include direction of travel, speed, time, weather conditions and any other factors contributing (last 4): to the accident. (Please use Page 3 if more space is required) Medical Information: Did you receive any medical treatment? Yes No If medical attention was required, give the treatment received and the doctor’s name and instructions: In your opinion, what contributed to the Incident? Unsafe Procedure Defective Equipment Excessive Speed Unsafe Practice Improper Equipment Failed to right of way Unauthorized Use Driver Inattention Other vehicle failed to observe traffic devices Horseplay Lack of Knowledge/Skill Other: *(complete below) Vehicle Maintenance Road Defects * Explain selection “Other” How would you prevent a recurrence of the same or similar accident? (Use Page 3 if more space is required) Employee’s Printed Name Title Employee’s Signature Date
COUNTY OF EL PASO Vehicle Traffic Accident Report Form Page 1 of 3 PART I (TO BE FILLED OUT BY THE INVOLVED EMPLOYEE) ALL TRAFFIC ACCIDENTS SHALL BE REPORTED WITHIN 48 HOURS TO HUMAN RESOURCES DEPARTMENT –RISK MANAGEMENT DIVISION Employee Name: D.O.B. DL#: Date of Hire Employee Home Address: Job Department: Time Shift Began: Week Day: Date of Accident Time of Accident: Location of Accident: Make: Model: VIN# (last 4): Vehicle Information: Year: Make: Model: VIN# (last 4): Describe details of the accident. Include direction of travel, speed, time, weather conditions and any other factors contributing to the accident. (Please use Page 3 if more space is required) Medical Information: Did you receive any medical treatment? Yes No If medical attention was required, give the treatment received and the doctor’s name and instructions: In your opinion, what contributed to the Incident? Unsafe Procedure Defective Equipment Excessive Speed Unsafe Practice Improper Equipment Failed to right of way Unauthorized Use Driver Inattention Other vehicle failed to observe traffic devices Horseplay Lack of Knowledge/Skill Other: *(complete below) Vehicle Maintenance Road Defects * Explain “Other” selection How would you prevent a recurrence of the same or similar accident? (Use Page 3 if more space is required) Employee’s Printed Name Title Employee’s Signature Date
Vehicle%20Traffic%20Accident%20Report%20Form.8.17.12.docx