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1. REPORT NO. REPUBLIC OF THE PHILIPPINES 2.

PROVINCIAL OFFICE
PHILIPPINE NATIONAL POLICE
3. POLICE STATION: TRAFFIC ACCIDENT REPORT FORM 4. REGIONAL OFFICE

5. NUMBER OF VEHICLES INVOLVED 9. ACCIDENT SEVERITY 10. Month 11. Day 12. Year
6. NUMBER OF DRIVER CASUALTIES F. Fatal Accident DATE:
7. NUMBER OF PASSENGER CASUALTIES S. Serious Injury Accident 13. Day of the Week
M Minor Injury Accident 14. TIME (Military Time)
8. NUMBER OF PEDESTRIAN CASUALTIES
D. Property Damage Only
15. JUNCTION (TYPE) 16. TRAFFIC CONTROL 17. COLLISION TYPE 18. MOVENMENT
1. None 1. Head On 6. Hit Object in Road 1. 1-Way
1. Not at Junction 5. Y 2. Centerline 2. Rear End 7. Hit Object Off Road 2.
3. Pedestrian Crossing 2-Way
3. Right Angle 8. Hit Parked Vehicle
2. 6. 4. School Crossing
4. Side Swipe 9. Hit Pedestrian
5. Police Controlled
3. 7. Railway 5. Overturned Vehicle 10. Hit Animal 19. SEPARATION
6. Traffic Lights
7. Stop Sign 1. Median
4. 8. Other 8. Give Way 11. Other ......................... 2. Not Median
9. Other ....................

20. WEATHER 21. LIGHT 22. ROAD CHARACTER 23. SURFACE 24. SURFACE TYPE 25. MAIN CLAUSE 26. ROAD CLASS
1. Fair 1. Straight+Flat CONDITION 1. Vehicle Defect 1. National
2. Rain 1. Daylight 2. Curve Only 1. Dry 1. Concrete 2. Road Defect 2. Provincial
3. Wind 2. Dawn/Dust 3. Incline Only 2. Wet 2. Asphalt
4. Smoke 3. Night (lit) 3. Muddy
3. Human Error 3. City
4. Curve+Incline 3. Gravel
5. Fog 4. Night (unlit) 4. Flooded 4. Other 4. Municipal
6. Dazzle 5. Bridge ......... 4. Earth
5. Other 5. Barangay
7. Storm 6. Crest
27. ROAD REPAIRS 28. HIT & RUN 29. LOCATION TYPE
1. Yes .................... 1. Yes .................... 1. Urban Area ....................
2. No ..................... 2. No ..................... 2. Rural Area .....................
LOCATION
Name of City/Town/Barangay: _________________________________ Distance ............... (km/m)
Landmark 1 ............................ Distance ............... (km/m)
Name of Road _____________________ BETWEEN
_______________ Landmark 2 ........................... Distance ............... (km/m)

JUNCTION ACCIDENT ONLY: Name of Second Road: Distance ............... (km/m)


LOCATION SKETCH MAP: Show site in relation to prominent landmarks COLLISION DIAGRAM SKETCH: Mark the position and direction of each
such as KM post or Major intersection. Mark distances to the landmarks vehicle and details of the road layout at the site of the accident

Signatures: Driver 1...................... .. Driver 2................................


POLICE DESCRIPTION OF ACCIDENT WITNESSES
1.Name:
Address:
2. Name:
Address:
INVESTIGATING OFFICER

SUPERVISING OFFICER

DRIVER STATEMENT ACTION TAKEN


Driver 1
RECOMMENDATION
Driver 2
STATUS OF CASE:
Additional Form(s) will be needed if there are more than 2 vehicles ; more than 4 passenger casualties or more than 2 pedestrian casualties.
Fill in the report no, provincial office, police station and dates and fix forms together securely
1. REP NO 2. PROV OFFICE 3. POL STN 4. REG OFFICE 5. DATE

VEHICLE 1 30. VEHICLE PLATE NUMBER DRIVER 1 Name:

31. OWNER’S NAME & ADDRESS ADDRESS

CHASSIS/NUMBER 32. ENGINE NUMBER LICENSE NUMBER:

33. INSURANCE OC/CR DETAILS LICENCES TYPE EXPIRY DATE

MANUFACTURER (MAKE) MODEL/YEAR 40 DRIVER SEX 42. DRIVER INJURY


1. Fatal 3. Minor
34. VEHICLE TYPE 35 VEHICLE MANUEVER 41. DRIVER AGE 2. Serious 4. Not Injured
1. Bicycle 7. Bus Hospital: ............................
1. Left Turn 7. Overtaking 13. Parked
2. Pedicab 8. Truck (Rigid) 2. Right Turn 8. Going Ahead on Rd 43. DRIVER ERROR
3. Motorcycle 9. Truck (Artic) 3. “U” Turn 9. Reversing 14. Other 1. None 6. No Signal
4. Tricycle 10. Van 4. Cross Traffic 10. Sudden Start 2. Fatigue/Asleep 7. Bad Overtaking
5. Car 11. Animal 5. Merging 11. Sudden Stop 3. Inattentive 8. Bad Turning
6. Jeepney 12 Other 6. Diverging 12. Parked off Road 4. Too Fast 9. Using Cell Phone
5. Too Close 10. Other ..........................................
36. LOADING 37. DIRECTION 38. VEHICLE DEFECT 39. VEHICLE DAMAGE 44. ALCOHOL/DRUGS 45. SEAT BELT/HELMET
1. Legal 1. North 1. None 5. Tire 1. None 5. Left 1. Alcohol Suspected 1. Seat Belt/Helmet Worn
2. Over Loaded 2. South 2. Lights 6. Multiple 2. Front 6. Multiple Drug Suspected 2. Not worn
3. Unsafe Load 3. East 3. Brakes 7. Other 3. Rear 7. Other 2. Not Suspected 3. Not Worn Correctly
4. West 4. Steering .............. 4. Right ..............

VEHICLE 2 30. VEHICLE PLATE NUMBER DRIVER 2 Name:

31. OWNER’S NAME & ADDRESS ADDRESS

CHASSIS/NUMBER 32. ENGINE NUMBER LICENSE NUMBER:

33. INSURANCE OC/CR DETAILS LICENCES TYPE EXPIRY DATE

MANUFACTURER (MAKE) MODEL/YEAR 40 DRIVER SEX 42. DRIVER INJURY


1. Fatal 3. Minor
34. VEHICLE TYPE 35 VEHICLE MANUEVER 41. DRIVER AGE 2. Serious 4. Not Injured
1. Bicycle 7. Bus Hospital: ............................
1. Left Turn 7. Overtaking 13. Parked
2. Pedicab 8. Truck (Rigid) 2. Right Turn 8. Going Ahead on Rd 43. DRIVER ERROR
3. Motorcycle 9. Truck (Artic) 3. “U” Turn 9. Reversing 14. Other 1. None 6. No Signal
4. Tricycle 10. Van 4. Cross Traffic 10. Sudden Start 2. Fatigue/Asleep 7. Bad Overtaking
5. Car 11. Animal 5. Merging 11. Sudden Stop 3. Inattentive 8. Bad Turning
6. Jeepney 12 Other 6. Diverging 12. Parked off Road 4. Too Fast 9. Using Cell Phone
5. Too Close 10. Other ..........................................
36. LOADING 37. DIRECTION 38. VEHICLE DEFECT 39. VEHICLE DAMAGE 44. ALCOHOL/DRUGS 45. SEAT BELT/HELMET
1. Legal 1. North 1. None 5. Tire 1. None 5. Left 1. Alcohol Suspected 1. Seat Belt/Helmet Worn
2. Over Loaded 2. South 2. Lights 6. Multiple 2. Front 6. Multiple Drug Suspected 2. Not worn
3. Unsafe Load 3. East 3. Brakes 7. Other 3. Rear 7. Other 2. Not Suspected 3. Not Worn Correctly
4. West 4. Steering .............. 4. Right ..............

PASSENGER CASUALTIES : Complete 1 Full Line for each passenger casualty = see reference boxes below
NAME AND ADDRESS 46. VEH. NO 47. SEX 48. AGE 49. INJURY/ HOSP 50. POSITION 51 Action

PEDESTRIAN CASUALTIES : Complete 1 Full Line for each pedestrian casualty = see reference boxes below
NAME AND ADDRESS 52. SEX 53. AGE 54. INJURY/ HOSP 55. POSITION 56 Action

49. PASSENGER INJURY 50. PASSENGER POSITION 51. PASSENGER 55.PEDESTRIAN 56. PEDESTRIAN
FOR 54. PEDESTRIAN INJURY 1. Front Seat ACTION LOCATION ACTION
REFERENCE 2. Rear Seat 1. None 1. On Pedestrian Crossing 1. None
ONLY F. Fatal 3. M/C Passenger 2. Boarding 2. Within 50m ped Crossing 2. Crossing Road
S. Serious 4. Bus Passenger 3. Alighting 3. On Central Refuge 3. Walking along Road
DO NOT
M Minor 5. Outside Sitting 4. Falling 4. In Road Centre 4. Walking along Edge
CIRCLE 6. Outside Standing 5. Other 5. On Footpath/Verge 5. Playing on Road
6. On Footpath