Attachment 7-Additional DHS 11000-25 Questions 2 (9).pdf
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- Attached to
- Training Support Services Federal contract opportunity
- Solicitation number
- 70LART25RPFB00006
About this file
This is Standard Form 94 (Rev. 2-83), "Statement of Witness" form, which is used to collect witness information for accidents involving government vehicles. The form requires detailed information about accident circumstances including time, date, location, description of the incident, witness position during the accident, injuries sustained, damage to private and government property, and vehicle speeds if applicable.
The form includes a diagram section for illustrating the accident scenario, with instructions for numbering vehicles (federal vehicle as 1, other vehicle as 2), showing direction of travel with arrows, and marking paths before and after the accident with solid and broken lines respectively. The form requires witness contact information including home and business addresses, telephone numbers, and signature. This appears to be a blank template form prescribed by GSA under FPMR 101-39.8 with OMB approval number 3090-0118.
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Text version
2. WHEN DID THE ACCIDENT HAPPEN?
STATEMENT OF WITNESS
(Attach additional sheets if necessary)
1. DID YOU SEE THE
ACCIDENT? FORM APPROVED
O.M.B. NUMBER
3090-0118
a. TIME b. DATEa.m.
p.m.
3. WHERE DID THE ACCIDENT HAPPEN? (Give street location and city)
4. TELL IN YOUR OWN WAY HOW THE ACCIDENT HAPPENED
5. WHERE WERE YOU WHEN THE ACCIDENT OCCURRED?
6. WAS ANYONE INJURED, AND IF SO, EXTENT OF INJURY IF KNOWN?
7. DESCRIBE THE APPARENT DAMAGE TO PRIVATE PROPERTY
8. DESCRIBE THE APPARENT DAMAGE TO GOVERNMENT PROPERTY 9. IF TRAFFIC CASE, GIVE
APPROXIMATE SPEED OF:
a. GOVERNMENT VEHICLE Miles per Hr.
b. OTHER VEHICLE Miles per Hr.
10. GIVE THE NAMES AND ADDRESSES OF ANY OTHER WITNESSES TO THE ACCIDENT (If known)
a. NAMES b. ADDRESSES (Include ZIP Code)
11. HOME ADDRESS (Include ZIP Code) 12. WITNESS (Print Name)
Sign here
WITNESS
COM-
PLETING
THIS
FORM 13. BUSINESS ADDRESS (Include ZIP Code)
a. HOME TELEPHONE NO.
b. TODAY'S DATE
TELEPHONE NO.
NSN 7540-00-634-4045
94-105
STANDARD FORM 94 (REV. 2-83)
Prescribed by GSA, FPMR 101-39.8
14. INDICATE ON THE DIAGRAM BELOW WHAT HAPPENED:
2. WHEN DID THE ACCIDENT HAPPEN?
STATEMENT OF WITNESS
(Attach additional sheets if necessary)
1. DID YOU SEE THE
ACCIDENT?
FORM APPROVED
O.M.B. NUMBER
3090-0118
a. TIME
b. DATE a.m.
p.m.
3. WHERE DID THE ACCIDENT HAPPEN? (Give street location and city)
4. TELL IN YOUR OWN WAY HOW THE ACCIDENT HAPPENED
5. WHERE WERE YOU WHEN THE ACCIDENT OCCURRED?
6. WAS ANYONE INJURED, AND IF SO, EXTENT OF INJURY IF KNOWN?
7. DESCRIBE THE APPARENT DAMAGE TO PRIVATE PROPERTY
8. DESCRIBE THE APPARENT DAMAGE TO GOVERNMENT PROPERTY
9. IF TRAFFIC CASE, GIVE
APPROXIMATE SPEED OF:
a. GOVERNMENT VEHICLE Miles per Hr.
b. OTHER VEHICLE Miles per Hr.
10. GIVE THE NAMES AND ADDRESSES OF ANY OTHER WITNESSES TO THE ACCIDENT (If known)
a. NAMES
b. ADDRESSES (Include ZIP Code)
11. HOME ADDRESS (Include ZIP Code)
12. WITNESS (Print Name) Sign here
WITNESS COM-PLETING THIS FORM
13. BUSINESS ADDRESS (Include ZIP Code) Z:\Library\GSA\GSA Road Image-1.tif
a. HOME TELEPHONE NO.
b. TODAY'S DATE
TELEPHONE NO.
NSN 7540-00-634-4045
94-105
STANDARD FORM 94 (REV. 2-83)
Prescribed by GSA, FPMR 101-39.8 \\iaimain\apps1\Pam_Ward\Logos\Pointer.jpg
14. INDICATE ON THE DIAGRAM BELOW WHAT HAPPENED:
8.2.1.3144.1.471865.466429
| 12. WITNESS (Print Name): | |
| a. HOME TELEPHONE NUMBER: | |
| 1. DID YOU SEE THE ACCIDENT?: | |
| 2. WHEN DID THE ACCIDENT HAPPEN? a. TIME: | |
| 2. WHEN DID THE ACCIDENT HAPPEN? a. TIME. a.m.: 0 | |
| 2. WHEN DID THE ACCIDENT HAPPEN? a. TIME. p.m.: 0 | |
| 3. WHERE DID THE ACCIDENT HAPPEN? (Give street location and city) | : |
| 4. TELL IN YOUR OWN WAY HOW THE ACCIDENT HAPPENED : | |
| 5. WHERE WERE YOU WHEN THE ACCIDENT OCCURRED?: | |
| 6. WAS ANYONE INJURED, AND IF SO, EXTENT OF INJURY IF KNOWN?: | |
| 7. DESCRIBE THE APPARENT DAMAGE TO PRIVATE PROPERTY: | |
| 8. DESCRIBE THE APPARENT DAMAGE TO GOVERNMENT PROPERTY: | |
| 9. IF TRAFFIC CASE, GIVE APPROXIMATE SPEED OF: a. GOVERNMENT VEHICLE in Miles per Hour: | |
| 9. IF TRAFFIC CASE, GIVE APPROXIMATE SPEED OF: b. OTHER VEHICLE in Miles per Hour: | |
| 10. GIVE THE NAMES AND ADDRESSES OF ANY OTHER WITNESSES TO THE ACCIDENT (If known). a. NAMES: | |
| 10. GIVE THE NAMES AND ADDRESSES OF ANY OTHER WITNESSES TO THE ACCIDENT (If known). b. ADDRESSES (Include ZIP Code): | |
| 11. HOME ADDRESS (Include ZIP Code): | |
| 13. BUSINESS ADDRESS (Include ZIP Code): | |
| TELEPHONE NUMBER: | |
| WITNESS SIGNATURE. This is a protected field.: | |
| WITNESS DIGITAL SIGNATURE: | |
| b. TODAY'S DATE. Enter 2 digit month, 2 digit day and 4 digit year.: | |
| 2. WHEN DID THE ACCIDENT HAPPEN? b. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
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