Attachment 2 Form SF 91 Motor Vehicle Accident Report.pdf
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- ENTERPRISE HEALTH UNIT SERVICES
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- 70LGLY26RGLB00001
About this file
This is Standard Form 91 (REV. 9/2020), a Motor Vehicle Accident (Crash) Report prescribed by GSA under the Federal Management Regulations. The form serves as a standardized template for federal agencies to document motor vehicle accidents involving federal vehicles, privately owned vehicles, or both.
The form is divided into thirteen sections designed to capture comprehensive crash information. Sections I through IX are completed by the vehicle operator and include federal vehicle data, other vehicle data, fatality or injury information, crash time and location, witness/passenger details, property damage, and police information. Section I requires the federal driver's name, license number, crash date, department/agency information, vehicle identification (tag number, year, make, model), estimated repair cost, seat belt usage, and vehicle damage description. Section IV requires the exact crash date, time, location (street address, city, state, ZIP code, nearest landmarks), and a diagram indicating what happened, with specific instructions for depicting vehicles, pedestrians, and railroad crossings. Section V documents witnesses and passengers, while Section VI captures property damage details including owner information, insurance company data, damaged items, locations, and estimated costs. Section VII collects police information including officer name, badge number, precinct, and violation charges.
Sections X through XIII are completed by the operator's supervisor and crash investigators. Section X details the trip origin, destination, purpose, times, route authorization, and scope of duty determination. Sections XI through XIII are completed only for crashes involving bodily injury, fatality, or damage exceeding $500, and include crash investigation data, conflicting information disclosure, interviews conducted, attachments, and final approvals and comments from both the crash investigator and reviewing official.
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b. DIRECTION OF PEDESTRIAN (Southwest (SW) corner to Northwest (NW) corner, etc.)
National Stock Number 7540-00-634-4041
Previous editions are NOT usable STANDARD FORM 91 (REV. 9/2020) Prescribed by GSA - FMR (41 CFR) 102-34.290
MOTOR VEHICLE
ACCIDENT (CRASH)
REPORT
Please read the Privacy Act
Statement on Page 4
INSTRUCTIONS: Sections I through IX are filled out by the vehicle operator. Section X, items 73 thru 83c are filled out by the operator's supervisor. Section XI thru XIII are filled out by a crash investigator for bodily injury, fatality, and/or damage exceeding $500.
SECTION I - FEDERAL VEHICLE DATA
3. DATE OF CRASH2. DRIVER'S LICENSE NUMBER/STATE/LIMITATIONS1. DRIVER'S NAME (Last, First, Middle)
4a. DEPARTMENT/FEDERAL AGENCY PERMANENT OFFICE ADDRESS 4b. TELEPHONE NUMBER
5. TAG OR IDENTIFICATION NUMBER 6. ESTIMATED REPAIR COST 7. YEAR OF VEHICLE 8. MAKE 9. MODEL 10. SEAT BELTS USED?
11. DESCRIBE VEHICLE DAMAGE
SECTION II - OTHER VEHICLE DATA (Use Section VIII if additional space is needed)
12. DRIVER'S NAME (Last, First, Middle) 13. SOCIAL SECURITY NUMBER/
TAX IDENTIFICATION NUMBER
14. DRIVER'S LICENSE NUMBER/STATE/LIMITATIONS
15a. DRIVER'S WORK ADDRESS 15b. TELEPHONE NUMBER
16a. DRIVER'S HOME ADDRESS 16b. HOME TELEPHONE NUMBER
17. DESCRIPTION OF VEHICLE DAMAGE 18. ESTIMATED REPAIR COST
19. YEAR OF VEHICLE 20. MAKE OF VEHICLE 21. MODEL OF VEHICLE 22. TAG NUMBER AND STATE
23a. DRIVER'S INSURANCE COMPANY NAME AND ADDRESS
24. VEHICLE IS 25a. OWNER'S NAME(S) (Last, First, Middle)
23b. POLICY NUMBER
23c. TELEPHONE NUMBER
25b. TELEPHONE NUMBER
CO-OWNED
LEASED
RENTAL
PRIVATELY OWNED
SECTION III - FATALITY OR INJURED (Use Section VIII if additional space is needed)
A
B
27. NAME (Last, First, Middle) 28. SEX 29. DATE OF BIRTH
30. ADDRESS
31. MARK "X" IN TWO APPROPRIATE BOXES 32. IN WHICH VEHICLE 33. LOCATION IN VEHICLE 34. FIRST AID GIVEN BY
35. TRANSPORTED BY 36. TRANSPORTED TO
37. NAME (Last, First, Middle) 38. SEX 39. DATE OF BIRTH
44. FIRST AID GIVEN BY43. LOCATION IN VEHICLE42. IN WHICH VEHICLE41. MARK "X" IN TWO APPROPRIATE BOXES
46. TRANSPORTED TO45. TRANSPORTED BY
40. ADDRESS
47.
PEDESTRIAN
a. NAME OF STREET OR HIGHWAY
FROM TO
c. DESCRIBE WHAT PEDESTRIAN WAS DOING AT TIME OF CRASH (crossing intersection with signal, against signal, diagonally; in roadway playing, walking, hitchhiking, etc.)
YES NO
FATALITY
FATALITY
INJURED
INJURED
DRIVER
DRIVER
HELPER
HELPER
PASSENGER
PASSENGER
PEDESTRIAN
PEDESTRIAN
FED
FED
OTHER (2)
OTHER (2)
26. OWNER'S ADDRESS(ES)
4c. E-MAIL ADDRESS
1. Number the vehicles involved as follows:
Government Vehicle (GOV) #1 - Private Vehicle (POV) #2 - Additional Vehicles GOV or POV as #3, etc. and show direction of travel by arrow.
(Example: ----> <----)
2. Use solid line to show path before crash Broken line after crash - - - - - - - - - - - -
3. Show pedestrian by ------------------------>
4. Show railroad by -|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|
5. Give names or numbers of streets or highways
6. Indicate north by arrow in this compass
STANDARD FORM 91 (REV. 9/2020) PAGE 2
SECTION IV - CRASH TIME AND LOCATION (Use Section VII if additional space is needed)
48. DATE OF CRASH 49. PLACE OF CRASH (Street address, city, state, ZIP Code; Nearest landmark; Distance nearest intersection; Kind of locality (industrial, business, residential, open country, etc.); Road description).
50. TIME OF CRASH
AM
PM
51. INDICATE ON THE DIAGRAMS BELOW WHAT HAPPENED
1 2
STANDARD FORM 91 (REV. 9/2020) PAGE 3
52. POINT OF IMPACT (Check one for each vehicle)
FED 2 AREA FED 2 AREA FED 2 AREA FED 2 AREA FED 2 AREA FED 2 AREA
a. Front b. Right Front c. Left Front d. Rear e. Right Rear f. Left Rear
g. Right Side h. Left Side
53. DESCRIBE WHAT HAPPENED (Refer to vehicles as "Fed", "2", "3", etc. Please include information on posted speed limit, approximate speed of vehicles, road conditions, weather conditions, driver visibility, condition of crash vehicles, traffic controls (warning light, stop signal, etc.), condition of light (daylight, dusk, night, dawn, artificial light, etc.), and driver actions (making a U-turn, passing, stopped in traffic, etc.).
SECTION V - WITNESS/PASSENGER (Witness must fill out Standard Form 94 - Statement of Witness) (Continue in Section VIII.)
A
B
54. NAME (Last, First, Middle) 55. TELEPHONE NUMBER 56. HOME TELEPHONE NUMBER
57. WORK ADDRESS 58. HOME ADDRESS
63. HOME ADDRESS62. WORK ADDRESS
61. HOME TELEPHONE NUMBER60. TELEPHONE NUMBER59. NAME (Last, First, Middle)
SECTION VI - PROPERTY DAMAGE (Use Section VIII if additional space is needed.)
64a. NAME OF OWNER (Last, First, Middle) 64b. TELEPHONE NUMBER 64c. HOME TELEPHONE NUMBER
64d. WORK ADDRESS 64e. HOME ADDRESS
65a. NAME OF INSURANCE COMPANY 65b. TELEPHONE NUMBER 65c. POLICY NUMBER
66. ITEM DAMAGED 67. LOCATION OF DAMAGED ITEM 68. ESTIMATED COST
SECTION VII - POLICE INFORMATION
69a. NAME OF POLICE OFFICER 69b. BADGE NUMBER 69c. TELEPHONE NUMBER
70. PRECINCT OR HEADQUARTERS 71a. PERSON CHARGED WITH CRASH 71b. VIOLATION(S) https://www.gsa.gov/forms-library/statement-witness
SECTION VIII - EXTRA DETAILS
SPACE FOR DETAILED ANSWERS. INDICATE SECTION AND ITEM NUMBER FOR EACH ANSWER. IF MORE SPACE IS NEEDED, CONTINUE ON ADDITIONAL SHEETS
OF PAPER.
STANDARD FORM 91 (REV. 9/2020) PAGE 4
PRIVACY ACT STATEMENT
The information on this form is subject to the Privacy Act of 1974 - United States Code set forth at 5 U.S.C. § 552a. Authority to collect the information is set forth at 40 U.S.C. § 491 and 31 U.S.C. § 7701. The information is required by Federal Government agencies to administer motor vehicle programs, including maintaining records on crashes involving privately owned and Federal fleet vehicles, and collecting crash claims resulting from crashes. Federal employees, and employees under contract, will use the information only in the performance of their official duties. Routine uses of the collected information may include disclosures to: appropriate Federal, State, or local agencies or contractors when relevant to civil, criminal, or regulatory investigations or prosecutions; the Office of Personnel Management and the Government Accountability Office for program evaluation purposes; a Member of Congress or staff in response to a request for assistance by the individual of record; another Federal agency, including the Department of the Treasury and the Department of Justice, or a court under judicial proceedings; agency Inspectors General in conducting audits; private insurance and the collection agencies (including agencies under contract to Treasury to collect debt), and to other agency finance offices for Federal management and debt collection.
Furnishing the requested information is mandatory, including the Social Security Number or Taxpayer's Identification Number (TIN) for use as a unique identifier to ensure accurate identification for individuals or firms in the system.
SECTION IX - FEDERAL DRIVER CERTIFICATION
I certify that the information on this form (Sections I thru VII) is correct to the best of my knowledge and belief.
72a. NAME AND TITLE OF DRIVER 72b. DRIVER'S SIGNATURE 72c. DATE
SECTION X - DETAILS OF TRIP DURING WHICH CRASH OCCURRED
73. ORIGIN 74. DESTINATION
75. EXACT PURPOSE OF TRIP
76. TRIP BEGAN
DATE TIME (Include AM or PM)
77. CRASH
OCCURRED
DATE TIME (Include AM or PM)
78. AUTHORITY FOR THE TRIP WAS GIVEN TO THE OPERATOR
ORALLY IN WRITING (Explain)
79. WAS THERE ANY DEVIATION FROM DIRECT ROUTE?
NO YES (Explain)
80. WAS THE TRIP MADE WITHIN ESTABLISHED WORKING HOURS?
YES NO (Explain)
81. DID THE OPERATOR, WHILE EN ROUTE, ENGAGE IN ANY ACTIVITY OTHER
THAN THAT FOR WHICH THE TRIP WAS AUTHORIZED?
NO YES (Explain)
82. COMPLETED
BY DRIVER'S
SUPERVISOR
a. DID THIS CRASH OCCUR WITHIN THE EMPLOYEE'S SCOPE OF DUTY?
YES
NO
b. COMMENTS
83a. NAME AND TITLE OF SUPERVISOR 83b. SUPERVISOR'S SIGNATURE 83c. DATE 83d. TELEPHONE NUMBER
STANDARD FORM 91 (REV. 9/2020) PAGE 5
SECTION XI - CRASH INVESTIGATION DATA
84. DID THE INVESTIGATION DISCLOSE CONFLICTING INFORMATION?
85. PERSONS INTERVIEWED
NAME NAMEDATE DATE
a.
b.
c.
d.
86. ADDITIONAL COMMENTS (Indicate section and item number of each comment)
SECTION XII - ATTACHMENTS
87. LIST ALL ATTACHMENTS TO THIS REPORT
SECTION XIII - COMMENTS/APPROVALS
88. REVIEWING OFFICIAL'S COMMENTS
89. CRASH INVESTIGATOR 90. CRASH REVIEWING OFFICIAL
a. SIGNATURE b. DATE
c. NAME (First, Middle, Last)
d. TITLE
e. OFFICE e. OFFICE
d. TITLE
c. NAME (First, Middle, Last)
b. DATEa. SIGNATURE
f. TELEPHONE NUMBER f. TELEPHONE NUMBEREXTENSION EXTENSION
NO YES (If checked, explain below.)
g. E-MAIL ADDRESS g. E-MAIL ADDRESS
b. DIRECTION OF PEDESTRIAN (Southwest (SW) corner to Northwest (NW) corner, etc.)
National Stock Number 7540-00-634-4041 Previous editions are NOT usable
STANDARD FORM 91 (REV. 9/2020)
Prescribed by GSA - FMR (41 CFR) 102-34.290
MOTOR VEHICLE
ACCIDENT (CRASH) REPORT
Please read the Privacy Act Statement on Page 4 INSTRUCTIONS: Sections I through IX are filled out by the vehicle operator. Section X, items 73 thru 83c are filled out by the operator's supervisor. Section XI thru XIII are filled out by a crash investigator for bodily injury, fatality, and/or damage exceeding $500.
SECTION I - FEDERAL VEHICLE DATA
3. DATE OF CRASH
2. DRIVER'S LICENSE NUMBER/STATE/LIMITATIONS
1. DRIVER'S NAME (Last, First, Middle) 4a. DEPARTMENT/FEDERAL AGENCY PERMANENT OFFICE ADDRESS 4b. TELEPHONE NUMBER
5. TAG OR IDENTIFICATION NUMBER
6. ESTIMATED REPAIR COST
7. YEAR OF VEHICLE
8. MAKE
9. MODEL
10. SEAT BELTS USED?
11. DESCRIBE VEHICLE DAMAGE
SECTION II - OTHER VEHICLE DATA (Use Section VIII if additional space is needed)
12. DRIVER'S NAME (Last, First, Middle)
13. SOCIAL SECURITY NUMBER/
TAX IDENTIFICATION NUMBER
14. DRIVER'S LICENSE NUMBER/STATE/LIMITATIONS
15a. DRIVER'S WORK ADDRESS 15b. TELEPHONE NUMBER 16a. DRIVER'S HOME ADDRESS 16b. HOME TELEPHONE NUMBER
17. DESCRIPTION OF VEHICLE DAMAGE
18. ESTIMATED REPAIR COST
19. YEAR OF VEHICLE
20. MAKE OF VEHICLE
21. MODEL OF VEHICLE
22. TAG NUMBER AND STATE
23a. DRIVER'S INSURANCE COMPANY NAME AND ADDRESS
24. VEHICLE IS
25a. OWNER'S NAME(S) (Last, First, Middle) 23b. POLICY NUMBER 23c. TELEPHONE NUMBER 25b. TELEPHONE NUMBER
CO-OWNED
LEASED
RENTAL
PRIVATELY OWNED
SECTION III - FATALITY OR INJURED (Use Section VIII if additional space is needed) A B
27. NAME (Last, First, Middle)
28. SEX
29. DATE OF BIRTH
30. ADDRESS
31. MARK "X" IN TWO APPROPRIATE BOXES
32. IN WHICH VEHICLE
33. LOCATION IN VEHICLE
34. FIRST AID GIVEN BY
35. TRANSPORTED BY
36. TRANSPORTED TO
37. NAME (Last, First, Middle)
38. SEX
39. DATE OF BIRTH
44. FIRST AID GIVEN BY
43. LOCATION IN VEHICLE
42. IN WHICH VEHICLE
41. MARK "X" IN TWO APPROPRIATE BOXES
46. TRANSPORTED TO
45. TRANSPORTED BY
40. ADDRESS
47. PEDESTRIAN
a. NAME OF STREET OR HIGHWAY
FROM
TO
c. DESCRIBE WHAT PEDESTRIAN WAS DOING AT TIME OF CRASH (crossing intersection with signal, against signal, diagonally; in roadway playing, walking, hitchhiking, etc.)
YES
NO
FATALITY
FATALITY
INJURED
INJURED
DRIVER
DRIVER
HELPER
HELPER
PASSENGER
PASSENGER
PEDESTRIAN
PEDESTRIAN
FED
FED
OTHER (2)
OTHER (2)
26. OWNER'S ADDRESS(ES)
4c. E-MAIL ADDRESS
1. Number the vehicles involved as follows:
Government Vehicle (GOV) #1 - Private Vehicle (POV) #2 - Additional Vehicles GOV or POV as #3, etc. and show direction of travel by arrow.
(Example: ----> <----)
2. Use solid line to show path before crash Broken line after crash - - - - - - - - - - - -
3. Show pedestrian by ------------------------>
4. Show railroad by -|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|
5. Give names or numbers of streets or highways
6. Indicate north by arrow in this compass
STANDARD FORM 91 (REV. 9/2020) PAGE 2
SECTION IV - CRASH TIME AND LOCATION (Use Section VII if additional space is needed)
48. DATE OF CRASH
49. PLACE OF CRASH (Street address, city, state, ZIP Code; Nearest landmark; Distance nearest intersection; Kind of locality (industrial, business, residential, open country, etc.); Road description).
50. TIME OF CRASH
AM
PM
51. INDICATE ON THE DIAGRAMS BELOW WHAT HAPPENED
51. Indicate on the diagrams below what happened. This diagram consists of a 4 way intersection with traffic lights on each side. Each side has 4 lanes separated by medians. 2 lanes going to the left, 2 lanes going up, 2 lanes going down, and 2 lanes going to the right.
.\Higway Diagram.PNG ..\Downloads\best-online-collection-of-free-to-use-clipart-contact-us-privacy-Yb9pkD-clipart.jpg
51. Indicate on the diagrams below what happened. This diagram consists of a curved road with 2 lanes separated by a yellow dashed dividing line.
.\Straight Road.PNG
51. Indicate on the diagrams below what happened. This diagram consists of a straight road with 2 sets of 2 lanes side by side separated by a median in the middle.
.\Business Objects Forms\Diamond for SF 94.PNG Yellow diamond symbol used to represent pedestrians.
..\..\Business Objects Forms\Compass for SF 94.PNG Image of a compass with 4 directions (North, South, East and West) used to indicate North.
STANDARD FORM 91 (REV. 9/2020) PAGE 3
52. POINT OF IMPACT (Check one for each vehicle)
52. POINT OF IMPACT
(Check one for each vehicle)
FED
AREA
FED
AREA
FED
AREA
FED
AREA
FED
AREA
FED
AREA
a. Front
b. Right Front
c. Left Front
d. Rear
e. Right Rear
f. Left Rear
g. Right Side
h. Left Side
53. DESCRIBE WHAT HAPPENED (Refer to vehicles as "Fed", "2", "3", etc. Please include information on posted speed limit, approximate speed of vehicles, road conditions, weather conditions, driver visibility, condition of crash vehicles, traffic controls (warning light, stop signal, etc.), condition of light (daylight, dusk, night, dawn, artificial light, etc.), and driver actions (making a U-turn, passing, stopped in traffic, etc.).
SECTION V - WITNESS/PASSENGER (Witness must fill out Standard Form 94 - Statement of Witness) (Continue in Section VIII.)
A B
54. NAME (Last, First, Middle)
55. TELEPHONE NUMBER
56. HOME TELEPHONE NUMBER
57. WORK ADDRESS
58. HOME ADDRESS
63. HOME ADDRESS
62. WORK ADDRESS
61. HOME TELEPHONE NUMBER
60. TELEPHONE NUMBER
59. NAME (Last, First, Middle) SECTION VI - PROPERTY DAMAGE (Use Section VIII if additional space is needed.)
64a. NAME OF OWNER (Last, First, Middle) 64b. TELEPHONE NUMBER 64c. HOME TELEPHONE NUMBER 64c. HOME TELEPHONE NUMBER 64d. WORK ADDRESS 64e. HOME ADDRESS 65a. NAME OF INSURANCE COMPANY 65b. TELEPHONE NUMBER 65c. POLICY NUMBER
66. ITEM DAMAGED
67. LOCATION OF DAMAGED ITEM
68. ESTIMATED COST
SECTION VII - POLICE INFORMATION
69a. NAME OF POLICE OFFICER 69b. BADGE NUMBER 69c. TELEPHONE NUMBER
70. PRECINCT OR HEADQUARTERS
71a. PERSON CHARGED WITH CRASH 71b. VIOLATION(S)
SECTION VIII - EXTRA DETAILS
SPACE FOR DETAILED ANSWERS. INDICATE SECTION AND ITEM NUMBER FOR EACH ANSWER. IF MORE SPACE IS NEEDED, CONTINUE ON ADDITIONAL SHEETS OF PAPER.
STANDARD FORM 91 (REV. 9/2020) PAGE 4
PRIVACY ACT STATEMENT
The information on this form is subject to the Privacy Act of 1974 - United States Code set forth at 5 U.S.C. § 552a. Authority to collect the information is set forth at 40 U.S.C. § 491 and 31 U.S.C. § 7701. The information is required by Federal Government agencies to administer motor vehicle programs, including maintaining records on crashes involving privately owned and Federal fleet vehicles, and collecting crash claims resulting from crashes. Federal employees, and employees under contract, will use the information only in the performance of their official duties. Routine uses of the collected information may include disclosures to: appropriate Federal, State, or local agencies or contractors when relevant to civil, criminal, or regulatory investigations or prosecutions; the Office of Personnel Management and the Government Accountability Office for program evaluation purposes; a Member of Congress or staff in response to a request for assistance by the individual of record; another Federal agency, including the Department of the Treasury and the Department of Justice, or a court under judicial proceedings; agency Inspectors General in conducting audits; private insurance and the collection agencies (including agencies under contract to Treasury to collect debt), and to other agency finance offices for Federal management and debt collection. Furnishing the requested information is mandatory, including the Social Security Number or Taxpayer's Identification Number (TIN) for use as a unique identifier to ensure accurate identification for individuals or firms in the system.
SECTION IX - FEDERAL DRIVER CERTIFICATION
I certify that the information on this form (Sections I thru VII) is correct to the best of my knowledge and belief.
72a. NAME AND TITLE OF DRIVER 72b. DRIVER'S SIGNATURE 72c. DATE
SECTION X - DETAILS OF TRIP DURING WHICH CRASH OCCURRED
73. ORIGIN
74. DESTINATION
75. EXACT PURPOSE OF TRIP
76. TRIP BEGAN
DATE
TIME (Include AM or PM)
77. CRASH
OCCURRED
DATE
TIME (Include AM or PM)
78. AUTHORITY FOR THE TRIP WAS GIVEN TO THE OPERATOR
ORALLY
IN WRITING (Explain)
79. WAS THERE ANY DEVIATION FROM DIRECT ROUTE?
NO
YES (Explain)
80. WAS THE TRIP MADE WITHIN ESTABLISHED WORKING HOURS?
YES
NO (Explain)
81. DID THE OPERATOR, WHILE EN ROUTE, ENGAGE IN ANY ACTIVITY OTHER THAN THAT FOR WHICH THE TRIP WAS AUTHORIZED?
NO
YES (Explain)
82. COMPLETED
BY DRIVER'S
SUPERVISOR
a. DID THIS CRASH OCCUR WITHIN THE EMPLOYEE'S SCOPE OF DUTY?
YES
NO
b. COMMENTS 83a. NAME AND TITLE OF SUPERVISOR 83b. SUPERVISOR'S SIGNATURE 83c. DATE 83d. TELEPHONE NUMBER
STANDARD FORM 91 (REV. 9/2020) PAGE 5
SECTION XI - CRASH INVESTIGATION DATA
84. DID THE INVESTIGATION DISCLOSE CONFLICTING INFORMATION?
85. PERSONS INTERVIEWED
NAME
NAME
DATE
DATE
a.
b.
c.
d.
86. ADDITIONAL COMMENTS (Indicate section and item number of each comment)
SECTION XII - ATTACHMENTS
87. LIST ALL ATTACHMENTS TO THIS REPORT
SECTION XIII - COMMENTS/APPROVALS
88. REVIEWING OFFICIAL'S COMMENTS
89. CRASH INVESTIGATOR
90. CRASH REVIEWING OFFICIAL
a. SIGNATURE
b. DATE
c. NAME (First, Middle, Last)
d. TITLE
e. OFFICE
e. OFFICE
d. TITLE
c. NAME (First, Middle, Last)
b. DATE
a. SIGNATURE
f. TELEPHONE NUMBER
f. TELEPHONE NUMBER
EXTENSION
EXTENSION
NO
YES (If checked, explain below.)
g. E-MAIL ADDRESS
g. E-MAIL ADDRESS 8.2.0.3062.1.452232.445150 Standard Form 91 - Motor Vehicle Accident (Crash) Report
| 24. Click here to select "Co-Owned" for the status of Vehicle Ownership.: 0 |
| 24. Click here to select "Leased" for the status of Vehicle Ownership.: 0 |
| 24. Click here to select "Rental" for the status of Vehicle Ownership.: 0 |
| 24. Click here to select "Privately Owned" for the status of Vehicle Ownership.: 0 |
| 10. Click here to select "Yes", Seat Belts were used by the Federal Driver. : 0 |
| 10. Click here to select "No", Seat Belts were NOT used by the Federal Driver.: 0 |
| 31. Click here to select "Fatality" as one of the two appropriate boxes for the first person involved in the Fatality or Injury.: 0 |
| 31. Click here to select "Injured" as one of the two appropriate boxes for the first person involved in the Fatality or Injury.: 0 |
| 31. Click here to select "Driver" as one of the two appropriate boxes for the first person involved in the Fatality or Injury.: 0 |
| 31. Click here to select "Helper" as one of the two appropriate boxes for the first person involved in the Fatality or Injury.: 0 |
| 31. Click here to select "Pedestrian" as one of the two appropriate boxes for the first person involved in the Fatality or Injury.: 0 |
| 31. Click here to select "Passenger" as one of the two appropriate boxes for the first person involved in the Fatality or Injury.: 0 |
| 32. Click here to select "Other (2)" as the vehicle where the fatality or injury occurred for the first person involved in the Fatality or Injury.: 0 |
| 32. Click here to select "Fed" as the vehicle where the Fatality or Injury occurred for the first person involved in the Fatality or Injury.: 0 |
| 42. If applicable, click here to select "Other (2)" as the vehicle where the Fatality or Injury occurred for the second person involved in the Fatality or Injury.: 0 |
| 42. If applicable, click here to select "Fed" as the vehicle where the Fatality or Injury occurred for the second person involved in the Fatality or Injury.: 0 |
| 41. If applicable, click here to select "Pedestrian" as one of the two appropriate boxes for the second person involved in the Fatality or Injury.: 0 |
| 41. If applicable, click here to select "Passenger" as one of the two appropriate boxes for the second person involved in the Fatality or Injury.: 0 |
| 41. If applicable, click here to select "Helper" as one of the two appropriate boxes for the second person involved in the Fatality or Injury.: 0 |
| 41. If applicable, click here to select "Driver" as one of the two appropriate boxes for the second person involved in the Fatality or Injury.: 0 |
| 41. If applicable, click here to select "Injured" as one of the two appropriate boxes for the second person involved in the Fatality or Injury.: 0 |
| 41. If applicable, click here to select "Fatality" as one of the two appropriate boxes for the second person involved in the Fatality or Injury.: 0 |
| 39. If applicable, enter the Date of Birth of the second person involved in the Fatality or Injury (enter 2 digit month, 2 digit day and 4 digit year).: |
| 1. Enter the Driver's Name (Last, First, Middle) of the Federal Vehicle..: |
| 4c. Enter the Federal Driver's Electronic Mail (E-Mail) Address.: |
| 4a. Enter the Federal Driver's Department/Federal Agency Permanent Office Address.: |
| 5. Enter the Federal Vehicle Tag or Identification Number.: |
| 4b. Enter the Federal Driver's Work Telephone Number. : |
| 8. Enter the Make of the Federal Vehicle. : |
| 7. Enter the Year of the Federal Vehicle. : |
| 9. Enter the Model of the Federal Vehicle.: |
| 11. Enter a description of the Damage to the Federal Vehicle. : |
| 12. Enter the Driver's Name (Last, First, Middle) of the Other Vehicle. : |
| 13. Enter the Other Driver's Social Security Number/Tax Identification Number. : |
| 14. Enter the Other Driver's License Number/State/Limitations.: |
| 15a. Enter the Other Driver's Work Address. : |
| 16a. Enter the Other Driver's Home Address.: |
| 17. Enter a description of the Damage to the Other Vehicle. : |
| 15b. Enter the Other Driver's Work Telephone Number. : |
| 16b. Enter the Other Driver's Home Telephone Number. : |
| 22. Enter the Other Vehicle's Tag Number and State. : |
| 21. Enter the Model of the Other Vehicle. : |
| 20. Enter the Make of the Other Vehicle. : |
| 19. Enter the Year of the Other Vehicle. : |
| 23a. Enter the Other Driver's Insurance Company Name and Address. : |
| 23b. Enter the Other Driver's Insurance Policy Number. : |
| 23c. Enter the Other Driver's Insurance Company's Telephone Number. : |
| 25b. Enter the Other Vehicle Owner's Telephone Number.: |
| 25a. Enter the Other Vehicle Owner's Name(s) (Last, First, Middle).: |
| 26. Enter the Other Vehicle Owner's Address(Es).: |
| 27. Enter the Name of the first person involved in the Fatality or Injury (Last, First, Middle).: |
| 28. Enter the gender of the first person involved in the Fatality or Injury. : |
| 30. Enter the Address of the first person involved in the Fatality or Injury. : |
| 33. Enter the location in the vehicle were the Fatality or Injury occurred for the first person involved in the Fatality or Injury.: |
| 34. Enter the name of the person or group who gave First Aid to the first person involved in the Fatality or Injury.: |
| 35. Enter the name of the person or group who transported the first person involved in the Fatality or Injury. : |
| 36. Enter the location where the first person involved in the Fatality or Injury was transported to. : |
| 37. If applicable, enter the Name of the second person involved in the Fatality or Injury (Last, First, Middle).: |
| 38. If applicable, enter the gender of the second person involved in the Fatality or Injury. : |
| 40. If applicable, enter the Address of the second person involved in the Fatality or Injury. : |
| 43. If applicable, enter the location in the vehicle were the Fatality or Injury occurred for the second person involved in the Fatality or Injury.: |
| 44. If applicable, enter the name of the person or group who gave First Aid to the second person involved in the Fatality or Injury.: |
| 45. If applicable, enter the name of the person or group who transported the second person involved in the Fatality or Injury. : |
| 46. If applicable, enter the location where the second person involved in the Fatality or Injury was transported to. : |
| 47a. Enter the Name of the Street or Highway where the Pedestrian was located. : |
| 47b. Enter the Direction the Pedestrian was coming from (e.g. Southwest (SW) corner). : |
| 47b. Enter the Direction the Pedestrian was going to (e.g. Northwest (NW) corner). : |
| 47c. Enter a description of what the Pedestrian was doing at the time of the crash (e.g. crossing intersection with signal, against signal, diagonally; in roadway playing, walking, hitchhiking, etc.): |
| 29. Enter the Date of Birth of the first person involved in the Fatality or Injury (enter 2 digit month, 2 digit day and 4 digit year).: |
| 6. Enter the Federal Vehicle's Estimated Repair Cost. : |
| 18. Enter the Other Vehicle's Estimated Repair Cost. : |
| 48. Enter the Date of Crash (enter 2 digit month, 2 digit day and 4 digit year).: |
| 50. Enter the Time of Crash. : |
| 49. Enter the location where the Crash occurred (e.g. Street Address, City, State, Zone Improvement Plan (ZIP) Code; Nearest Landmark; Distance Nearest Intersection; Kind of Locality (Industrial, Business, Residential, Open Country, etc.); Road Description).: |
| 50. Click here to select "PM" to indicate the crash occurred after 12 Noon but before 12 AM. : 0 |
| 50. Click here to select "AM" to indicate the crash occurred after 11:59 PM but before 12 Noon. : 0 |
| 52. Click here to select "2" for Area a. Front for the Point of Impact.: 0 |
| 52. Click here to select "FED" for Area a. Front for the Point of Impact.: 0 |
| 52. Click here to select "2" for Area b. Right Front for the Point of Impact.: 0 |
| 52. Click here to select "FED" for Area b. Right Front for the Point of Impact.: 0 |
| 52. Click here to select "2" for Area c. Left Front for the Point of Impact.: 0 |
| 52. Click here to select "FED" for Area c. Left Front for the Point of Impact.: 0 |
| 52. Click here to select "2" for Area d. Rear for the Point of Impact.: 0 |
| 52. Click here to select "FED" for Area d. Rear for the Point of Impact.: 0 |
| 52. Click here to select "2" for Area e. Right Rear for the Point of Impact.: 0 |
| 52. Click here to select "FED" for Area e. Right Rear for the Point of Impact.: 0 |
| 52. Click here to select "2" for Area f. Left Rear for the Point of Impact.: 0 |
| 52. Click here to select "FED" for Area f. Left Rear for the Point of Impact.: 0 |
| 52. Click here to select "2" for Area g. Right Side for the Point of Impact.: 0 |
| 52. Click here to select "FED" for Area g. Right Side for the Point of Impact.: 0 |
| 52. Click here to select "2" for Area h. Left Side for the Point of Impact.: 0 |
| 52. Click here to select "FED" for Area h. Left Side for the Point of Impact.: 0 |
| 53. Enter a description of what happened (refer to vehicles as "Fed", "2", "3", etc. Please include information on posted speed limit, approximate speed of vehicles, road conditions, weather conditions, driver visibility, condition of crash vehicles, traffic controls (warning light, stop signal, etc.), condition of light (daylight, dusk, night, dawn, artificial light, etc.), and driver actions (making a U-turn, passing, stopped in traffic, etc.).: |
| 54. Enter the Name (Last, First, Middle) of the first Witness/Passenger. : |
| 55. Enter the first Witness/Passenger's Telephone Number. : |
| 56. Enter the first Witness/Passenger's Home Telephone Number. : |
| 57. Enter the first Witness/Passenger's Work Address. : |
| 58. Enter the first Witness/Passenger's Home Address.: |
| 59. If applicable, enter the Name (Last, First, Middle) of the second Witness/Passenger. : |
| 60. If applicable, enter the second Witness/Passenger's Telephone Number. : |
| 61. If applicable, enter the second Witness/Passenger's Home Telephone Number. : |
| 63. If applicable, enter the second Witness/Passenger's Home Address.: |
| 62. If applicable, enter the second Witness/Passenger's Work Address. : |
| 64a. Enter the Owner's Name (Last, First, Middle) of the damaged property. : |
| 64b. Enter the damaged property owner's Telephone Number. : |
| 64c. Enter the damaged property owner's Home Telephone Number. : |
| 64d. Enter the damaged property owner's Work Address. : |
| 64e. Enter the damaged property owner's Home Address. : |
| 65a. Enter the Name of the Owner's Insurance Company.: |
| 65b. Enter the Insurance Company's Telephone Number.: |
| 65c. Enter the Insurance Company's Policy Number.: |
| 66. Enter the Name of the Damaged Item. : |
| 67. Enter the Location of the Damaged Item.: |
| 69a. Enter the Name of the Police Officer responding to the crash. : |
| 69b. Enter the Police Officer's Badge Number.: |
| 69c. Enter the Police Officer's Telephone Number.: |
| 71b. Enter the Violation(s) occurring as a result of the crash. : |
| 71a. Enter the Name of the Person the Police Officer has Charged with the Crash. : |
| 70. Enter the Police Officer's Precinct or Headquarters.: |
| 68. Enter the Estimated Cost to repair or replace the Damaged Item.: |
| Enter any Extra Details. Indicate Section and Item Number for Each Answer. If more space is needed, continue on additional sheets of paper. If filling out electronically, click on the attachment paper clip located on the left side panel and click on the paper clip with the plus sign to attach your additional sheets to this form. : |
| 78. Click here to select "In Writing" as the Authority Given to the Operator for the Trip. : 0 |
| 78. Click here to select "Orally" as the Authority Given to the Operator for the Trip. : 0 |
| 79. Click here to select "Yes" There was Deviation from the intended Direct Route.: 0 |
| 79. Click here to select "No" There was NOT any Deviation from the intended Direct Route.: 0 |
| 80. Click here to select "No" the Trip was NOT Made within Established Working Hours.: 0 |
| 80. Click here to select "Yes" the Trip was Made within Established Working Hours.: 0 |
| 81. Click here to select "Yes" the Operator, while en route, did Engage in any Activity other than that for which the Trip was Authorized. : 0 |
| 81. Click here to select "No" the Operator, while en route, did NOT Engage in any Activity other than that for which the Trip was Authorized. : 0 |
| 82. If you are the Federal Driver's Supervisor, click here to select "No" the Crash did NOT occur within the Employee's Scope of Duty. : 0 |
| 82. If you are the Federal Driver's Supervisor, click here to select "Yes" the Crash did occur within the Employee's Scope of Duty. : 0 |
| 72c. If you are the Federal Driver, enter the date you signed this form (enter 2 digit month, 2 digit day and 4 digit year).: |
| 76. Enter the Date the Trip Began (enter 2 digit month, 2 digit day and 4 digit year).: |
| 77. Enter the Date the Crash Occurred (enter 2 digit month, 2 digit day and 4 digit year).: |
| 83c. If you are the Federal Driver's Supervisor, enter the Date you signed this form (enter 2 digit month, 2 digit day and 4 digit year).: |
| 72a. Enter the Name and Title of the Driver who's filled out Sections 1 - 7 of this form.: |
| 73. Enter the Origin (starting point) of the trip. : |
| 74. Enter the intended Destination (ending point) of the Trip. : |
| 75. Enter the Exact Purpose of the Trip.: |
| 76. Enter the Time the Trip Began (Include AM or PM).: |
| 77. Enter the Time the Crash Occurred (Include AM or PM).: |
| 82. If you are the Federal Driver's Supervisor, enter any additional comments you may have here. : |
| 83d. Enter the Federal Driver's Supervisor Telephone Number. : |
| 83a. Enter the Name and Title of the Federal Driver's Supervisor. : |
| 78. If "In Writing" was selected, explain this authority given to the operator here. : |
| 79. If "Yes" was selected, Explain any Deviations from the intended Direct Route here. : |
| 80. If "No" was selected, explain why the trip was NOT made within established working hours here. : |
| 81. If "Yes" was selected, explain why the Operator, while en route, Engaged in Activity other than that for which the Trip was Authorized here. : |
| 90a. Sign here if you are the Crash Reviewing Official. : |
| 84. Click here to select "No" the Investigation did NOT Disclose Conflicting Information.: 0 |
| 84. Click here to select "Yes" the Investigation did Disclose Conflicting Information.: 0 |
| 85a. Enter the Date when the first person was interviewed (enter 2 digit month, 2 digit day and 4 digit year).: |
| 85b. If applicable, enter the Date when the second person was interviewed (enter 2 digit month, 2 digit day and 4 digit year).: |
| 85c. If applicable, enter the Date when the third person was interviewed (enter 2 digit month, 2 digit day and 4 digit year).: |
| 85d. If applicable, enter the Date when the fourth person was interviewed (enter 2 digit month, 2 digit day and 4 digit year).: |
| 89b. If you are the Crash Investigator, enter the Date you signed this form (enter 2 digit month, 2 digit day and 4 digit year).: |
| 90b. If you are the Crash Reviewing Official, enter the Date you signed this form (enter 2 digit month, 2 digit day and 4 digit year).: |
| If Yes was checked, explain the disclosure of conflicting information from the investigation here. : |
| 85a. Enter the Name of the first person interviewed. : |
| 85b. If applicable, enter the Name of the second person interviewed. : |
| 85c. If applicable, enter the Name of the third person interviewed. : |
| 85d. If applicable, enter the Name of the fourth person interviewed. : |
| 86. Enter any Additional Comments (indicate section and item number of each comment).: |
| 87. List all Attachments to this Report. If filling out electronically, click on the attachment paper clip located on the left side panel and click on the paper clip with the plus sign to add the attachments listed to this form. : |
| 88. If you are the Reviewing Official, enter any comments you may have here. : |
| 89c. Enter the Name of the Crash Investigator (First, Middle, Last).: |
| 90c. Enter the Name of the Crash Reviewing Official (First, Middle, Last).: |
| 89g. Enter the Crash Investigator's Electronic Mail (E-Mail) Address.: |
| 90g. Enter the Crash Reviewing Official's Electronic Mail (E-Mail) Address.: |
| 90e. Enter the Crash Reviewing Official's Office info.: |
| 89e. Enter the Crash Investigator's Office info.: |
| 89f. Enter the Crash Investigator's Telephone Number. : |
| 89f. If applicable, enter the Crash Investigator's Telephone Number Extension.: |
| 90f. Enter the Crash Reviewing Official's Telephone Number. : |
| 90f. If applicable, enter the Crash Reviewing Official's Telephone Number Extension.: |
File details come from the government source that posted it. Updated .