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Accident Report
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* Indicates required question
Employee Name
*
Your answer
Date of Accident
*
MM
/
DD
/
YYYY
Time of Accident
*
Time
:
AM
PM
Truck Number
*
Your answer
Trailer Number
*
Your answer
Short Description of Accident
*
Your answer
Location of Accident
*
Your answer
Where other parties involved
*
Yes
No
Required
Did the JIT-EX Employee receive a ticket/citation
*
Yes
No
Was there a service call made for repairs
*
Yes
No
Was any vehicle towed?
*
Yes
No
Was any party taken to the hospital from the scene?
*
Yes
No
Was there a fatality?
*
Yes
No
If the JIT-EX employee was ticketed and any vehicle was towed or anyone was taken to the hospital, then our driver is required to take a drug test. Was a drug test administered.
*
Yes
No
Where was the driver sent to take a drug screen
Your answer
Name of person filing the report
*
Your answer
Safety Management this was reported to
*
Choose
Wesley Boland
April Riddle
Ben Harrison
Robby Harris
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