Attachment 2 Motor Vehicle Accident Report.pdf

Attachment 2 LOGISTIC SUPPORT SERVICES

MOTOR VEHICLE

ACCIDENT REPORT

Please read the Privacy Act State-ment on Page 3

INSTRUCTIONS: Sections I through IX are filled out by the vehicle operator. Section X, items 72 thru 82c are filled on by the operator's supervisor. Sections XI thru XIII are filled out by an accident investigator for bodily injury, fatality, and/or damage exceeding $500.

SECTION I - FEDERAL VEHICLE DATA

1. DRIVER'S NAME (Last, first, middle) 2. DRIVER'S LICENSE NO./STATE/LIMITATIONS DATE OF ACCIDENT

4a. DEPARTMENT/FEDERAL AGENCY PERMANENT OFFICE ADDRESS 4b. WORK TELEPHONE NUMBER

5. TAG OR IDENTIFICATION NUMBER 6. EST. REPAIR COST

7. YEAR OF VEHICLE 8. MAKE 9. MODEL 10. SEAT BELTS USED

YES NO

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 NO./

TAX IDENTIFICATION NO.

14. DRIVER'S LICENSE NO./STATE/LIMITATIONS

15. a DRIVER'S WORK ADDRESS 15b. WORK TELEPHONE NUMBER

16a. DRIVER'SHOME 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. DRIVE'S INSURANCE COMPANY NAME AND ADDRESS 23b. POLICY NUMBER

23c. TELEPHONE NUMBER

24. VEHICLE IS

CO-OWNED RENTAL

LEASED PRIVATELY OWNED

25a. OWNER'S NAME(S) (Last, first, middle) 25b. TELEPHONE NUMBER

26. OWNER'S ADDRESS(ES)

SECTION III - KILLED OR INJURED (Use Section VIII if additional space is needed)

Attachment 2 RFP 70LGLY21RGLB00001 Logistic Support Services

NSN 7540-00-634-4041

Previous edition not usable

STANDARD FORM 91 (2/2004)

Prescribed by GSA-FMR 102-34.295

27. NAME (last, first, middle) 28. SEX

33. LOCATION IN VEHICLE

35. TRANSPORTED BY

37. NAME (last, first, middle) 38. SEX

42. IN WHICH VEHICLE

FED

OTHER (2)

43. LOCATION IN VEHICLE

45. TRANSPORTED BY

a. NAME OF STREET OR HIGHWAY

FROM

29. DATE OF BIRTH

30. ADDRESS

A 31. MARK "X" IN TWO APPROPRIATE BOXES

DRIVER

HELPER

32. IN WHICH VEHICLE

FED

OTHER (2)

34. FIRST AID GIVEN BY

KILLED

INJURED

PASSENGER

PEDESTRIAN

36. TRANSPORTED TO

39. DATE OF BIRTH

40. ADDRESS

B 41. MARK "X" IN TWO APPROPRIATE BOXES 44. FIRST AID GIVEN BY

KILLED DRIVER PASSENGER

INJURED HELPER PEDESTRIAN

46. TRANSPORTED TO

47. Pedes-trian

b. DIRECTION OF PEDESTRIAN (SW corner to NW corner, etc.)

TO

c. DESCRIBE WHAT PEDESTRIAN WAS DOING AT TIME OF ACCIDENT (crossing intersection with signal, against signal, diagonally; in roadway playing, walking, hitchhiking, etc.)

SECTION IV - ACCIDENT TIME AND LOCATION (Use section VII if additional space is needed.)

48. DATE OF ACCIDENT 49. PLACE OF ACCIDENT (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 ACCIDENT

AM

PM

51. INDICATE ON THIS DIAGRAM HOW THE ACCIDENT HAPPENED 52. POINT OF IMPACT

(Check one for each vehicle)

FED 2 AREA

a. Front

b. R. Front

c. L. Front

d. Rear

e. R. Rear

f. L. Rear

g. R. Side

h. L. 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, weather conditions, driver visibility, condition of accident 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 SF 94, Statement of Witness) (Continue in Section VIII.)

A

54. NAME (Last, first, middle) 55. WORK TELEPHONE NUMBER 56. HOME TELEPHONE NUMBER

57. WORK ADDRESS 58. HOME ADDRESS

B

59. NAME (Last, first, middle) 60. WORK TELEPHONE NUMBER 61. HOME TELEPHONE NUMBER

62. WORK ADDRESS 63. HOME ADDRESS

SECTION VI - PROPERTY DAMAGE (Use Section VIII if additional space is needed.)

64a. NAME OF OWNER (Last, first, middle) 64b. WORK 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 ACCIDENT 71b. VIOLATION(S)

Attachment 2

SECTION VIII - EXTRA DETAILS

SPACE FOR DETAILED ANSWERS. INDICATE SECTION AND ITEM NUMBER FOR EACH ANSWER. IF MORE SPACE IS NEEDED, CONTINUE ITEMS ON PLAIN BOND

PAPER.

PRIVACY ACT STATEMENT

The information on this form is subject to the Privacy Act of 1974 (5 U.S.C. section 552a). Authority to collect the information is Title 40 U.S.C. Section 491 and the title 31 U.S.C. Section 7701. The formation is required by federal Government agencies to administer motor vehicle programs, including maintaining records on accidents involving privately owned and Federal fleet vehicles,and collecting accident claims resulting from accidents. 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 General Accounting 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 Treasury and 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.

SECTION X - DETAILS OF TRIP DURING WHICH ACCIDENT OCCURRED

75. EXACT PURPOSE OF TRIP

76. TRIP BEGAN

DATE TIME (Include AM or PM)

77. ACCIDENT

OCCURRED

DATE TIME (Include AM or PM)

78. AUTHOURITY 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 ENROUTE, 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 ACCIDENT OCCUR WITHIN THE EMPLOYEE'S SCOPE OF DUTY

YES

NO

b. COMENTS

83a. NAME AND TITLE OF SUPERVISOR 83b. SUPERVISOR'S SIGNATURE AND DATE 83c. TELEPHONE NUMBER

73. ORIGIN 74. DESTINATION

72a. NAME AND TITLE OF DRIVER 72b. DRIVER'S SIGNATURE AND DATE

SECTION XI - ACCIDENT INVESTIGATION DATA

85. PERSONS INTERVIEWED

NAME DATE NAME 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

88. REVIEWING OFFICIAL'S COMMENTS

SECTION XIII - COMMENTS/APPROVALS

89. ACCIDENT INVESTIGATOR 90. ACCIDENT REVIEWING OFFICIAL

a. SIGNATURE b. DATE a. SIGNATURE b. DATE

c. NAME (First, middle, last) c. NAME (First, middle, last)

d. TITLE d. TITLE

e. OFFICE e. OFFICE

f. OFFICE TELEPHONE NUMBER f. OFFICE TELEPHONE NUMBER

AREA CODE NUMBER EXTENSION AREA CODE NUMBER EXTENSION

84. DID THE INVESTIGATION DISCLOSE CONFLICTING INFORMATION. NO YES (If checked, explain below.)