Collision Questionnaire

COLLISION CHECKLIST
Date:
1.
2.
3.
4.
5.
Offer Assistance. Give First Aid To The

Injured.
Call State, Provincial Or Local Police
Immediately, To Report Any Collision
Resulting In Injury To Any Person Or Motor
Vehicle Damage.
If Ambulance And/Or Physician Is Required,
Make Clear This Is For Emergency Treatment
Only.
Make No Admission Or Take Any Blame For
The Collision.
GET NAMES OF WITNESSES
Emergency Phone Numbers

Police: ___________________________________________
Fire: _____________________________________________
Ambulance: _______________________________________
Doctor: __________________________________________
GET NAMES OF INJURED

INJURED
Name:
Address:
Injuries:
Age:
Taken to:
Sex:
INJURED
Name:
Address:
Injuries:
Age:
Taken to:
Sex:
GET THE DETAILS

Date:
Time:
Location:
City:
Streets:
Speed: Other...........Km/hr
VEHICLE DAMAGE
Vehicle Damage (Yours):
Vehicle Damaged (Other):
Your...........Km/hr
Estimated Cost of Repair:
OTHER CIRCUMSTANCES
(Check one or more for each driver)
#
#
1
2
Physical defects
_______________________________________
Extreme fatigue
Driving under the influence of intoxicants
Exceeded lawful speed
Did not grant right of way to vehicle
Did not grant right of way to pedestrian
Followed too closely
Improper passing
On wrong side of road
Going straight
Failed to give proper signal
Turning left
Turning right
Improper turn
Disregarded stop light
Disregarded stop sign
Disregarded other traffic control
Slowing or stopping
Improper starting from parked position
Parked or standing
Improper parking location
Backing
Glasses worn
Other important actions:

___________________
NOTES
Notes:_______________________________________________
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_______________________________________
Police Officer: ______________________________
Badge No.: _________________________________
Location: __________________________________
CHECK THESE POINTS

Road Character
Traffic Control
Straight road
Curve
Level
On grade
Hillcrest
Road Surface
Light
Daylight
Dusk
Dawn
Darkness street lighted
Darkness not street
lighted
Dry
Wet
Muddy
Snowy
Icy
Clay
Gravel
Packed
Loose
Pavement
Weather
Road Effects
Under repair
Defective shoulders
Holes, deep ruts, bumps
Loose material on surface
Obstruction
Specify Other_____________
No defects
Condition of other vehicle

#
#
#
1
2
1
Apparently good
Glaring
headlights
Tail light out or
obscured
Puncture blow
out
Stop Sign
Stop light
Officer or flagman
No traffic control present
Cloudy
Clear
Raining
Snowing
Fog
Smoke
Sleet
#
2
Defective brakes
Defective
steering
Defective
headlights
Other defects
______________
Collision involving a pedestrian

Crossing at intersection
Condition
With signal
Normal
Against Signal
Careless
No signals
Confused
Diagonally
Intoxicated
Standing on sidewalk
Physical defect
Standing in a safety zone
Walking in road
Crossing between intersections
Getting on or off another vehicle
Children playing on highway
At work in roadway
Riding or hitching on vehicle
Walking on rural highway or bridge
Coming from behind parked vehicle or object
Coming from behind moving vehicle or object
Crossing highway
OTHER VEHICLE NO.1

Driver:
Age:
Address:
Phone:
Drivers Lic. & Year:
Relationship to Owner:
Car Lic.:
Year:
Make Type & Year:
Car Colour:
Owner:
Home #:
Bus #:
No. of Passengers:
Insured: Yes
No
Policy No.:
Name of Insurance Agent:
OTHER VEHICLE NO.2

Driver:
Age:
Address:
GET NAMES & LICENSE NUMBERS
Prov:
Injured:
Phone:
Drivers Lic. & Year:
Relationship to Owner:
Car Lic.:
Year:
Make Type & Year:
Car Colour:
Owner:
Home:
Bus:
No. of Passengers:
Insured: Yes
No
Policy No.:
Name of Insurance Agent:
Prov:
Injured:
DRAW A SKETCH
1.
2.
3.
4.
5.
6.
7.
Take all measurements skid marks, road widths etc

Identify point of impact
Indicate centre line of road
Outline roadway with solid lines identify all streets
Indicate bridges
Indicate railway crossings & show if guarded
Identify vehicles
Y for your vehicle
Indicate North
O for other vehicle
X for 3rd vehicle
-------------------------------------------------------------Witness Card/Tmoin
Would you kindly write your name and address below. This will be of great assistance in preparing full report.
Je serais trs oblig de bien vouloir indiquer ci-dessous vos nom et adresse ces renseignements me seront trs
utiles pour tablir mon rapport.
Name/Nom:_______________________________________
Address/Adresse:__________________________________
Business/Bureau: __________________________________
Telephone Numbers/Numros de Tlphone
Residence/Rsidence:_______________________________
Business/Bureau:__________________________________
Name/Nom:_______________________________________
Address/Adresse:__________________________________
Business/Bureau: __________________________________
Business/Bureau:__________________________________
Name/Nom:_______________________________________
Address/Adresse:__________________________________
Business/Bureau: __________________________________
Business/Bureau:__________________________________
Name/Nom:_______________________________________
Address/Adresse:__________________________________
Business/Bureau: __________________________________
Business/Bureau:__________________________________
Name/Nom:_______________________________________
Address/Adresse:__________________________________
Business/Bureau: __________________________________
Business/Bureau:__________________________________
Name/Nom:_______________________________________
Address/Adresse:__________________________________
Business/Bureau: __________________________________
Business/Bureau:__________________________________
Name/Nom:_______________________________________
Address/Adresse:__________________________________
Business/Bureau: __________________________________
Business/Bureau:__________________________________
Name/Nom:_______________________________________
Address/Adresse:__________________________________
Business/Bureau: __________________________________
Business/Bureau:__________________________________

Collision Questionnaire

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Collision Questionnaire

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COLLISION CHECKLIST

Offer Assistance. Give First Aid To The

Emergency Phone Numbers

GET NAMES OF INJURED

GET THE DETAILS

Vehicle Damaged (Other):

Estimated Cost of Repair:

Driving under the influence of intoxicants

Exceeded lawful speed

Did not grant right of way to vehicle

Did not grant right of way to pedestrian

Followed too closely

On wrong side of road

Failed to give proper signal

Disregarded stop light

Disregarded stop sign

Disregarded other traffic control

Improper starting from parked position

Improper parking location

Other important actions:

CHECK THESE POINTS

Condition of other vehicle

Collision involving a pedestrian

OTHER VEHICLE NO.1

OTHER VEHICLE NO.2

GET NAMES & LICENSE NUMBERS

Take all measurements skid marks, road widths etc

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