Accident Report Form
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1
2ACCIDENT REPORT FORM
Please fill out form as completely as possible.
Branch _________________________________
Customer ___________________________________________
Driver _______________________________________
Employee Staffmark I.D. Number __________________
Date of Incident _______________
Time of Incident _______________
City & State where incident occurred __________________________________________________________________
___ Motor vehicle collision ___ Property damage without collision ___ Cargo ___ Equipment
Fatalities? ___YES ___ NO
Injuries? ___YES ___NO
Any vehicles towed? ___YES ___NO
Was Staffmark driver cited? ___YES
___NO
If so, for what violation(s) ____________________________________
Reporting Police Department & Report Number __________________________________________________________
Staffmark driver was operating: ___ Tractor-trailer ___Straight Truck/Van ___Bobtail Tractor ___ Forklift ___Other
Describe damage to your vehicle:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Collided with: ___ Moving Vehicle(s) ___Parked Vehicle(s)
___ Pedestrian/Bicycle(s) ___ Fixed Object(s) ___Other
Describe damage to other vehicle/property:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Other Party Involved in Incident
Name/Address/Phone Number
Number of Passengers _____
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Witnesses (Name/Address/Phone Number):
_________________________________________________________________________________________________
_________________________________________________________________________________________________
******************************************************************************************************************************************
For Staffmark Personnel Use Only:
___ Safety Department Notified ___By Phone
___By Email
___Report faxed to Safety Department
___Non-DOT post-accident UDS
___ DOT post-accident UDS
___DOT post-accident BAT
Issued By:
Issue Date:
Revision Date:
Form #:
Page 1 of 2
Safety
05/01/2004
02/08/2012
TRANS 138
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Parent category: Business