Heavy Vehicle Incident Reporting Form

HEAVY VEHICLE INCIDENT REPORTING FORM

This form is to be completed for all heavy vehicle incidents and returned within 48 hours of the incident occurring, whether or not injury / damage have been sustained. The reporting of this heavy vehicle incident to Main Roads Heavy Vehicle Services does not relate to the requirement to report on-road incidents as required under road law.

Incident Details /

Date:

/

Time (24hrs):

/

Location:

(Road name/s, nearest town or other identifying feature)

/

Road Type & Condition:

(Sealed, unsealed, wet, gradient, curved, etc.) /
Incident Description: /

Main Reason Why Incident Occurred:

/

Incident Type:

/ ☐ Animal strike ☐ Crash (injury only) ☐ Crash (injury and damage) ☐ Vehicle failure ☐ Vehicle rollover ☐ Vehicle separation
☐ Near miss ☐ Damage (no injury but property damage)
Other, state below /

Damage Sustained to:

/ ☐ Towing Vehicle ☐ Trailer/s ☐ 3rd parties vehicle
☐ Bridge / structure ☐ Road surface ☐ Roadside furniture
☐ None
Other, state below /

Damage Details:

/

Injury Type:

/ ☐ 1st aid ☐ Hospital admission ☐ Medical / doctors ☐ Fatality ☐ N/A /
Vehicle Details /
Vehicle Configuration: /

Vehicle Registration Numbers:

/ Prime Mover / Truck: /
Trailer/s: /

Load Description:

/

Dangerous Goods:

/ ☐ Yes ☐ No /

Dangerous Goods Class:

/

Main Roads WA Permit Type & Number:

/
Operator Details
/
Operator Number:
/
Operator Name:
/
Contact Name:
/
Contact Phone Number:
/
Email Address:
/
Driver Details /
Name: /
Company: /
Contact Number: /
Witness Details /
Name: /
Company: /
Contact Number: /
Notification Details /
Emergency Services Notified: / ☐ Yes ☐ No ☐ N/A /
Which Service/s: / ☐ DFES ☐ St Johns Ambulance WA ☐ WA Police /
Police Officer / Station: / Crash identification No: /
Main Roads WA: / ☐138 138 ☐ Regional Office / Feedback / Incident No: /
Notified Parties Who Attended The Incident: / ☐ DFES ☐ St Johns Ambulance WA ☐ WA Police
☐ Main Roads Regional Officer /
Traffic Management Required: / ☐ Yes ☐ No
If yes, please specify /
Corrective Action/s /
/ Close Out Date: /
Action to Prevent Recurrence /
/ Close Out Date: /

Reported By

Name: /
Contact Number: /
Date: /
Time: /
Photos /

Email completed form to:

Main Roads WA Heavy Vehicle Services

PO Box 374 | WELSHPOOL DC | WA 6986 | Telephone 138 486 Page 3 of 3