INCIDENT REPORT

Use this form to report accidents, injuries, medical situations, criminal activities, traffic incidents, or Truckers Against Trafficking. If possible, a report should be completed within 24 hours of the event.

Date of Report *

Person Involved

Full Name *

Address *

City *

State *

Zip Code

ID #

Phone *

Email *

The Incident

Date of Incident *

Time of Incident *

Location of Incident *

Describe The Incident *

Injuries

Was Anyone Injured? *

Yes

No

If Yes, Describe the Injuries

Witness

Was There a Witness? *

Yes

No

Witness' First Name

Witness' Last Name

Witness' Phone Number

Witness' Email Address

Additional Comments

Police & Medical Services

Was the Police Notified? *

Yes

No

If Yes, Was a Report Filed?

Yes

No

Report Number

Was Medical Treatment Provided? *

Yes

No

Did You Refuse Treatment?

Yes

No

Was another car/truck/person involved? If yes, describe the other party and injuries/ damages. *

Additional Comments 1

Where Were You Treated?

Did the Fire Department assist? *

Upload photos *

Person Filing Report

Signature

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Print Name

Date Signed

FOR OFFICIAL USE ONLY

Report Received By

First Name

Last Name

Date Received

Follow Up Action Taken

Signature

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