Motor Vehicle Accident Report Form

Part A – Event Information

General

School/Site:
Date of Event: / Time of Event:
Date Reported: / 1st Reported to:
1st Reported to – First Name: / 1st Reported to – Last Name:
Event ID:

Accident Information

Type of Vehicle Accident:
Description of Accident:
Police Notified? / Officer Name:
Officer Report Number:
Road Conditions: / Weather:
Damage to property other than vehicle?
Damage to other property details:

Location

Did accident occur at school? / Location:
Location details:

Part B – Involved People Information

Involved Person

Involved Person is a: / Role:
Passenger in what vehicle? / Wearing seatbelt?
First Name: / Last Name:
Gender: / Phone Number:
Email Address:
Date of Birth: / Grade:
Driver’s License #: / Employee ID:
Service Unit/Department: / Covered by WCB?

Vehicle Information

Vehicle Type: / Vehicle Owner:
Make: / Model:
Year: / Serial Number:
License Plate #: / Province:
Unit Number:
Rental Company: / Phone Number:
Description of Vehicle Damage:

Injuries/First Aid

Was the person injured? / First Aid Administered?
Description of First Aid:
First Aider’s 1st Name: / First Aider’s Last Name:
Qualified First Aider? / First Aider Qualification:
EMS Called? / Transported by EMS?
EMS Destination:
Further Medical Attention Sought? / What type?
Were there any pre-existing medical conditions?

Type of Injuries

Injury/Illness Type / Body Part / Left/Right/NA

Legal

Has legal action been threatened?
Details:

Media

Media has been involved or likely to be involved?
Details:

Submission Details:

Submitter’s First Name: / Submitter’s Last Name:
Email: / Phone:
Supervisor:
Supervisor’s First Name: / Supervisor’s Last Name:
Supervisor’s Email:
Date Submitted:

Personal information is collected under the authority of Section 33c of Alberta’s Freedom of Information and Protection of Privacy Act (FOIP). This information will be used to respond to potential emergency situations involving the person whom you have identified above. It will be treated in accordance with the privacy protection provisions of the FOIP Act.

For any additional information or questions, please contact: [Enter name or email address]