Attachment 3 Form SF 94 Statement of Witness.pdf
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- Attached to
- ENTERPRISE HEALTH UNIT SERVICES
- Solicitation number
- 70LGLY26RGLB00005
About this file
This is Standard Form 94 (Rev. 11/2020), a federal government witness statement form prescribed by the General Services Administration under 41 CFR 102-34. The form is used to collect detailed accounts of motor vehicle accidents involving government or privately owned vehicles. It is subject to the Privacy Act of 1974 and carries OMB Control Number 3090-0118, with an expiration date of December 31, 2023. The estimated completion time is 20 minutes.
The form requires witnesses to provide comprehensive accident information, including their contact details (name, address, email, and telephone numbers), accident specifics (date, time, and location), and a narrative account of how the accident occurred. Witnesses must describe road and environmental conditions, apparent damage to both government and private property, injuries sustained, and any unusual circumstances preceding or during the incident. The form includes diagram sections where witnesses indicate vehicle positions, directions of travel, pedestrian locations, and other relevant details using standardized symbols and notation conventions. Additionally, a notes section requests information about the number of drivers and vehicles involved, vehicle descriptions, passenger counts, and whether law enforcement or emergency services responded. The form concludes with witness name, signature, date, and time fields. Authority to collect this information derives from 40 U.S.C. § 491 and 31 U.S.C. § 7701, and collected data may be disclosed to federal, state, and local agencies for civil, criminal, or regulatory purposes, as well as to insurance carriers and collection agencies.
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Text version
5. WAS ANYONE INJURED, AND IF SO, EXTENT OF INJURY IF KNOWN?
STATEMENT OF WITNESS
(Attach additional sheets if necessary)
Please read the Privacy Act Statement on Page 3
OMB Control Number: 3090-0118 Expiration Date: 12/31/2023
STANDARD FORM 94 (REV. 11/2020)
Prescribed by GSA - FMR (41 CFR) 102-34
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 3090-0118. We estimate that it will take 20 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.
c. E-MAIL ADDRESS
b. HOME ADDRESS (Include ZIP Code)
a. NAME OF WITNESS:
1. WITNESS INFORMATION
f. HOME TELEPHONE NUMBER e. CELLULAR TELEPHONE NUMBER d. WORK TELEPHONE NUMBER p.m.
a.m. d. TIME YOU ARRIVED AT SCENE?a. DID YOU WITNESS THE ACCIDENT?
2. ACCIDENT INFORMATION
6. DESCRIBE THE APPARENT DAMAGE TO PRIVATE PROPERTY.
4. TELL IN YOUR OWN WAY HOW THE ACCIDENT HAPPENED.
3. WHERE DID THE ACCIDENT OCCUR? (Give Street Location, City, and State)
9. DID YOU NOTICE ANYTHING UNUSUAL PRIOR TO OR DURING THE ACCIDENT?
IF YES, PLEASE DESCRIBE WHAT YOU NOTICED AND WHY YOU THINK IT WAS PERTINENT TO THIS ACCIDENT.
8. DESCRIBE ROAD AND CONDITIONS THAT INFLUENCED THE ACCIDENT (e.g. weather, terrain, debris, road work, time of day).
7. DESCRIBE THE APPARENT DAMAGE TO GOVERNMENT PROPERTY.
b. DATE OF ACCIDENT: c. TIME OF ACCIDENT:
p.m.
a.m.
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 accident Broken line after accident - - - - - - - - -
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 94 (REV. 11/2020) PAGE 2
10. INDICATE ON THE DIAGRAMS BELOW WHAT HAPPENED.
1 2
TIME:DATE: 13. WITNESS SIGNATURE:
12. WITNESS NAME:
NOTES: Include other pertinent information such as: How many drivers/vehicles were involved? Describe the vehicles. How many passengers per vehicle(s)?
Were Police, Fire and/or Rescue on the scene? Was a Police Report completed? Were Police, Fire and/or Rescue present before or after you arrived on the scene? Describe the accident (provide your detailed account).
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 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 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.
STANDARD FORM 94 (REV. 11/2020) PAGE 3
PRIVACY ACT STATEMENT
5. WAS ANYONE INJURED, AND IF SO, EXTENT OF INJURY IF KNOWN?
STATEMENT OF WITNESS
(Attach additional sheets if necessary) Please read the Privacy Act Statement on Page 3 OMB Control Number: 3090-0118 Expiration Date: 12/31/2023
STANDARD FORM 94 (REV. 11/2020)
Prescribed by GSA - FMR (41 CFR) 102-34 Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 3090-0118. We estimate that it will take 20 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.
c. E-MAIL ADDRESS
b. HOME ADDRESS (Include ZIP Code)
a. NAME OF WITNESS:
1. WITNESS INFORMATION
f. HOME TELEPHONE NUMBER
e. CELLULAR TELEPHONE NUMBER
d. WORK TELEPHONE NUMBER p.m.
a.m.
d. TIME YOU ARRIVED AT SCENE?
a. DID YOU WITNESS THE ACCIDENT?
2. ACCIDENT INFORMATION
6. DESCRIBE THE APPARENT DAMAGE TO PRIVATE PROPERTY.
4. TELL IN YOUR OWN WAY HOW THE ACCIDENT HAPPENED.
3. WHERE DID THE ACCIDENT OCCUR? (Give Street Location, City, and State)
9. DID YOU NOTICE ANYTHING UNUSUAL PRIOR TO OR DURING THE ACCIDENT?
IF YES, PLEASE DESCRIBE WHAT YOU NOTICED AND WHY YOU THINK IT WAS PERTINENT TO THIS ACCIDENT.
8. DESCRIBE ROAD AND CONDITIONS THAT INFLUENCED THE ACCIDENT (e.g. weather, terrain, debris, road work, time of day).
7. DESCRIBE THE APPARENT DAMAGE TO GOVERNMENT PROPERTY.
b. DATE OF ACCIDENT:
c. TIME OF ACCIDENT:
p.m.
a.m.
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 accident Broken line after accident - - - - - - - - -
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 94 (REV. 11/2020) PAGE 2
10. INDICATE ON THE DIAGRAMS BELOW WHAT HAPPENED.
10. 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 .\Straight Road.PNG
10. 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.
..\Downloads\best-online-collection-of-free-to-use-clipart-contact-us-privacy-Yb9pkD-clipart.jpg
10. Indicate on the diagrams below what happened. This diagram consists of a curved road with 2 lanes separated by a dashed dividing line.
.\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.
TIME:
DATE:
\\iaimain\apps1\Pam_Ward\Logos\Pointer.jpg Marker indicating where to sign the form (at Item 13, Witness Signature).
13. WITNESS SIGNATURE:
12. WITNESS NAME:
NOTES: Include other pertinent information such as: How many drivers/vehicles were involved? Describe the vehicles. How many passengers per vehicle(s)? Were Police, Fire and/or Rescue on the scene? Was a Police Report completed? Were Police, Fire and/or Rescue present before or after you arrived on the scene? Describe the accident (provide your detailed account).
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 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 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.
STANDARD FORM 94 (REV. 11/2020) PAGE 3
PRIVACY ACT STATEMENT
8.2.1.3144.1.471865.466429 Standard Form 94 - Statement of Witness
| 7. Enter the Apparent Damage to Government Property. : | |
| 6. Enter the Apparent Damage to Private Property. : | |
| 12. Enter the Witness Name. : | |
| 1b. Enter the Witness Home Address (include Zone Improvement Plan (ZIP) Code). : | |
| 1f. Enter the Witness Home Telephone Number. : | |
| 1d. Enter the Witness Work Telephone Number. : | |
| 2c. Click here to select p.m. for the Time of Accident. : 0 | |
| 2c. Click here to select p.m. for the Time of Accident. : 0 | |
| 2c. Click here to select a.m. for the Time of Accident. : 0 | |
| 2c. Click here to select a.m. for the Time of Accident. : 0 | |
| 2c. Enter the Time of Accident. : | |
| 2a. State Yes or No if you witnessed the accident. : | |
| 5. Enter if Anyone was Injured, and if so, Extent of the Injury, if known. : | |
| 4. Enter In Your Own Way How the Accident Happened. : | |
| 3. Enter Where the Accident Occurred. (Give Street Location, City, and State) | : |
| 8. Enter a Description of the Road and Conditions that Influenced the Accident (e.g. weather, terrain, debris, road work, time of day).: | |
| 2b. Enter the Date of Accident (enter 2 digit month, 2 digit day, and 4 digit year).: | |
| Enter any additional notes about what you saw regarding the accident. Include other pertinent information such as: How many drivers/vehicles were involved? Describe the vehicles. How many passengers per vehicle(s)? Were Police, Fire and/or Rescue on the scene? Was a Police Report completed? Were Police, Fire and/or Rescue present before or after you arrived on the scene? Describe the accident (provide your detailed account).: |
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