Time Was the driver injured? Yes No Location of the accident Describe the circumstances of the accident Draw a diagram of the accident scene, showing the position of all vehicles and any persons injured 3 Details of driver's vehicle Registration number of the vehicle driven at the time of the accident State of registration Vehicle type (car, truck, motor cycle) Name and address of owner—if not the driver What was the estimated at time of impact Mark the points of impact on the diagram with an X Home address Home telephone number Work telephone number Mobile telephone number 5 Details of other occupants in driver's vehicle Show by number, the position in the vehicle for other occupants on the diagram Position number Surname names Home address Home telephone number Work telephone number Mobile telephone number Was this person injured? Yes No 6 Details of all other vehicles involved in the accident Surname Given names Home address Registration number Number of persons in vehicle Level of damage (see question 3 for levels 1 to 4) 7 Details of all other persons involved in the accident (not in a vehicle at the time of the accident) Surname Given names Home address Type of road user (e.g. pedestrian, cyclist etc.) Was this person injured? Yes No Declaration by person making this report I hereby declare that the above information is true and correct to the best of my knowledge and belief. Signature
Date FORM 3 Regulation 8(2) 1 Name of Authority Returned to 2 Details of Transport Authority/Operator involved Vehicle types End Vehicle Identification Numbers Destinations Time table 3 Authority/Operator driver details Surname Given names Employee identification number Male/Female 4 Accident details Date of accident Day of the week Time a.m./p.m. Location of the accident Description of the accident Visibility good/bad Weather wet/dry Lighting on/off Draw a diagram of the accident showing the position of all vehicles and any injured person as at time of impact 5 Police details Did the police attend the accident scene— No Yes If yes please provide the following details— Name of the police officer who attended at the scene Police officer's badge number Station where officer located 6 Details of persons injured in Authority/Operator Vehicle Surname Given names Residential address Home telephone number Work telephone number Mobile telephone number Male/Female Age Apparent injuries sustained to hospital by ambulance— No Yes If yes, name of hospital
Name of the MTA officer or loss assessor if attended at the 7 Details of other injured persons Surname Given names Residential address Home telephone number Work telephone number Mobile telephone number Male/Female Age Registration number if in a vehicle Type of road user Apparent injuries sustained Taken to hospital by ambulance— No Yes If yes, name of hospital 8 Details of all other vehicles involved in the accident Surname Given names Residential address Home telephone number Work telephone number Mobile telephone number Registration number 9 Details of witnesses Surname Given names Residential address Home telephone number Work telephone number Mobile telephone number Did an authority employee witness the accident? Yes No 10 General remarks Have you any doubt the injury occurred as stated? If so why? Completed by Name Position Signature Date If report is from tourist railway/tram operator Name of operator Address Telephone number