Incident and Collision Investigation Form

Capture the full picture of a depot event, road collision or theft in one submission: who was involved, where and when it happened, injuries sustained and the treatment given. Drivers, operatives and managers can add third-party details, witness notes and photographs. Fleet and safety teams then hold everything needed to notify insurers and regulators.

Use this template

Page 1

Name

Nombre

Apellido

Which Depot are you based at?

Date and time on which you completed this form

Time

Are you reporting an incident, a road traffic collision or a theft? Note: road traffic collision notifications must be accompanied by Appendix C of the accident reporting procedure, completed in full by our driver.

Page 2

Position

Phone Number

If this matter relates to theft of hired equipment, who was it on hire to at the time of the theft?

Type of Person

Name

Nombre

Apellido

Age

Phone Number

Job Title

Approximately how long have they been in their current role?

How many hours had the operative been working when this incident occurred?

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Time of Incident

Date of Incident

Page 3

Location of Incident

Our driver's vehicle registration

Plant number or registration (thefts)

Our vehicle type

Third party vehicle registration

Local speed limit

Speed traveling

Third party driver(s) names

Third party driver's contact number

Details of third party insurers

Third party policy number

Third party car make, model and colour

Who was at fault for this collision?

Select the type of injury

What was involved

Briefly describe the incident, including any equipment or processes being used and any damage

Describe any circumstances that may have contributed to the incident

How many days did the employee take off as a result of this incident?

Police incident number

Page 4

What type of injury or ill health was sustained or suspected

What part of the body was injured?

Did they need resuscitation?

Did they become unconscious?

Did they remain in hospital for more than 24 hours?

Did the injured person go directly to hospital from the incident scene?

Outcome of incident

Name of first aider in attendance (if first aid was provided)

Treatment received

Enter details of any witnesses below

Page 5

What were conditions like before the incident occurred, for example noise, temperature, lighting, dust, fumes, weather and time of day

Provide details of training and experience if this was an employee

Describe the level of supervision and safety management in force at the time of the incident

Upload photo 1

Max 10 MB per file

Upload photo 2

Max 10 MB per file

Upload photo 3

Max 10 MB per file

Upload multiple files (photos or video)

Max 10 MB per file

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