Lumiform Mobile audits & inspections
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Accident Incident Report Form

Use this accident incident report form in case someone got hurt as a result of a crash. It can be used by fleet managers to report all the details of the incident. Use this template to help the inspector to capture all contact information and verification information of the harmed/wounded person and describe full details of the injury and the accident. S/he can also attach photo(s) as proof and document emergency services involvement (i.e. police, fire department,…), hospitalization data and witness statements. In the end, the form can be signed by all involved people.
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General Information
Name of driver:
Car registration number:
Driver's license number:
Injured Person Background
Name of the injured person
His/Her Identification number
Attach photo of ID:
Date of Birth:
Telephone Number:
Injury Details
Date and time of injury:
How exactly did the accident happen?
Describe the affected body part.
Attach a photo of the body part that was injured. Comment if necessary.
Attach photo of the surrounding of the location of the accident.
Were safety regulations used?
Witness Statements
Were there any witnesses?
Emergency Services
Did the injured went to doctor/ hospital?
Was the police called?
Sign off
Full name and signature of the injured person:
Full name and signature of the fleet manager:
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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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