Attachment 19-SF-91 - Motor Vehicle Accident Report Form.pdf
Standard Form PDF 227 KB Posted
- Attached to
- Transportation Service FLETC Artesia, NM
- Solicitation number
- 70LART25RPFB00007
About this file
This is Standard Form 91 (SF-91), a Motor Vehicle Accident Report form used by federal agencies to document motor vehicle accidents involving federal vehicles. The form contains 13 sections designed to capture comprehensive details about vehicle accidents: Federal Vehicle Data, Other Vehicle Data, Killed or Injured, Accident Time and Location, Witness/Passenger Information, Property Damage, Police Information, Extra Details, Federal Driver Certification, Details of Trip, Accident Investigation Data, Attachments, and Comments/Approvals.
The form requires detailed documentation including driver information, vehicle details, damage descriptions, accident diagrams, injury reports, and witness statements. It includes specific fields for trip authorization, scope of duty determination, and supervisor review. This appears to be a blank template form that would be used in conjunction with the transportation services contract at the Federal Law Enforcement Training Center in Artesia, NM, where contractors may need to report any vehicle accidents that occur during service delivery.
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Text version
1_DRIVERS_NAME_Last_first:
| 2_DRIVERS_LICENSE_NOSTATE: |
| 3_DATE_OF_ACCIDENT: |
| 4a_DEPARTMENTFEDERAL_AGEN: |
| Comb1: |
| Comb11: |
| 5_TAG_OR_IDENTIFICATION_N: |
| FillText6: |
| 7_YEAR_OF_VEHICLE: |
| 8_MAKE: |
| 9_MODEL: |
| 10_SEAT_BELTS_USED: Off |
| 1_1_DESCRIBE_VEHICLE_DAMA: |
| 12_DRIVERS_NAME_Last_firs: |
| 13_DRIVERS_LICENSE_NUMBER: |
| 14a_DRIVERS_WORK_ADDRESS: |
| Comb2: |
| Comb21: |
| 15a_DRIVERS_HOME_ADDRESS: |
| Comb3: |
| Comb31: |
| 16_DESCRIBE_VEHICLE_DAMAG: |
| FillText7: |
| 18_YEAR_OF_VEHICLE: |
| 19_MAKE_OF_VEHICLE: |
| 20_MODEL_OF_VEHICLE: |
| 21_TAG_NUMBER_AND_STATE: |
| 22a_DRIVERS_INSURANCE_COM: |
| 22b_POLICY_NUMBER: |
| Comb4: |
| Comb41: |
| COOWNED: Off |
| LEASED: Off |
| RENTAL: Off |
| PRIVATELY_OWNED: Off |
| 24a_OWNERS_NAMES_Last_fir: |
| Comb5: |
| Comb51: |
| SECTION_III__KILLED_OR_IN: |
| 26_NAME_Last_first_middle: |
| 27_SEX: |
| 28_DATE_OF_BIRTH: |
| 29_ADDRESS: |
| KILLED1: Off |
| INJURED1: Off |
| DRIVER1: Off |
| HELPER1: Off |
| PASSENGER1: Off |
| PEDESTRIAN1: Off |
| FED1: Off |
| OTHER_2: Off |
| 32_LOCATION_IN_VEHICLE: |
| 33_FIRST_AID_GIVEN_BY: |
| 34_TRANSPORTED_BY: |
| 35_TRANSPORTED_TO: |
| 36_NAME_Last_first_middle: |
| 37_SEX: |
| 38_DATE_OF_BIRTH: |
| 39_ADDRESS: |
| KILLED2: Off |
| INJURED2: Off |
| DRIVER2: Off |
| HELPER2: Off |
| PASSENGER2: Off |
| PEDESTRIAN2: Off |
| FED2: Off |
| OTHER_1: Off |
| 42_LOCATION_IN_VEHICLE: |
| 43_FIRST_AID_GIVEN_BY: |
| 44_TRANSPORTED_BY: |
| 45_TRANSPORTED_TO: |
| a_NAME_OF_STREET_OR_HIGHW: |
| FROM: |
| TO: |
| c_DESCRIBE_WHAT_PEDESTRIA: |
| 47_DATE_OF_ACCIDENT: |
| 48_PLACE_OF_ACCIDENT_Stre: |
| FillText8: |
| FillText9: |
| FED3: |
| FED4: |
| FED5: |
| FED6: |
| FED7: |
| FED8: |
| FED9: |
| FED10: |
| 1: |
| 3: |
| 4: |
| 5: |
| 6: |
| 7: |
| 8: |
| 9: |
| SECTION_V__WITNESSPASSENG: |
| 53_NAME_Last_first_middle: |
| Comb7: |
| Comb71: |
| Comb8: |
| Comb81: |
| 56_BUSINESS_ADDRESS: |
| 57_HOME_ADDRESS: |
| 58_NAME_Last_first_middle: |
| Comb9: |
| Comb91: |
| Comb10: |
| Comb101: |
| 61_BUSINESS_ADDRESS: |
| 62_HOME_ADDRESS: |
| 63a_NAME_OF_OWNER: |
| Comb111: |
| Comb6: |
| Comb12: |
| Comb121: |
| 63d_BUSINESS_ADDRESS: |
| 63e_HOME_ADDRESS: |
| 64a_NAME_OF_INSURANCE_COM: |
| Comb13: |
| Comb131: |
| 64c_POLICY_NUMBER: |
| 65_ITEM_DAMAGED: |
| 66_LOCATION_OF_DAMAGED_IT: |
| 67_ESTIMATED_COST: |
| 68a_NAME_OF_POLICE_OFFICE: |
| 68b_BADGE_NUMBER: |
| Comb14: |
| Comb141: |
| 69_PRECINCT_OR_HEADQUARTE: |
| 70a_PERSON_CHARGED_WITH_A: |
| 70b_VIOLATIONS: |
| SECTION_IX__FEDERAL_DRIVE: |
| 71_a_NAME_AND_TITLE_OF_DR: |
| 72_ORIGIN: |
| 73_DESTINATION: |
| FillText10: |
| DATE1: |
| FillText11: |
| FillText12: |
| DATE2: |
| FillText13: |
| FillText14: |
| ORALLY: Off |
| IN_WRITING_Explain: Off |
| FillText15: |
| 78_WAS_THERE_ANY_DEVIATIO: Off |
| FillText16: |
| 79_WAS_THE_TRIP_MADE_WITH: Off |
| FillText17: |
| 80_DID_THE_OPERATOR_WHILE: Off |
| FillText18: |
| a_DID_THIS_ACCIDENT_OCCU1: Off |
| b_COMMENTS: |
| 82a_NAME_AND_TITLE_OF_SUP: |
| 71b_DRIVER_DATE: |
| Comb15: |
| Comb151: |
| SECTION_XI__ACCIDENT_INVE: Off |
| 84_PERSONS_INTERVIEWED: |
| a_b: |
| DATE3: |
| FillText20: |
| FillText21: |
| d_C: |
| DATE4: |
| FillText19: |
| FillText22: |
| SECTION_XII__ATTACHMENTS: |
| SECTION_XIII__COMMENTSAPP: |
| FillText23: |
| 82b_SUPERVISOR_DATE: |
| b_NAME_First_middle_last: |
| c_TITLE: |
| d_OFFICE: |
| Comb16: |
| Comb161: |
| 87a_date: |
| 88a_date: |
| b_NAME_First_middle_last1: |
| c_TITLE1: |
| d_OFFICE1: |
| Comb17: |
| Comb171: |
File details come from the government source that posted it. Updated .