Form T-840A Accident/Incident Report - Utah

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Utah Department of Transportation
T-840a
Print Form
Accident/Incident Report
Vehicle #1 is the state vehicle, any other vehicle(s) involved are #2. Fields marked with
*
are required. If more than 2 vehicles are involved
separate
please attach a
piece of paper with all the information.
Report Date
*Emp. Drivers Lic. #
*UDOT Veh. Vin. #
*Date of Accident
*Time of Accident (HH:MM)
Date & Time Unknown (old damage, not hit & run)
*Road on which accident happened, with nearest intersection
*
Was vehicle off the paved surface when the accident happened?
Nearest City of Accident
*State
Zip Code
*Weather Conditions
*Road Surface Conditions
Estimated Speed (use numbers)
Responding Police Dept.
Police Case #
*Make
*Model year
*License plate #
*Vehicle #
*Emp. ID #
*Operator
Job title
*Region Address
*City
Zip
*State
*Work Phone (Emp.)
*Employee Gender
Cell Phone (Emp.)
Was the operator of vehicle #1 wearing a seatbelt?
Was the operator of vehicle #1cited?
Was the operator of any other involved vehicles cited?
Was the operator of vehicle #1 talking on a cell phone?
Were there any passengers in vehicle #1?
Was the operator of vehicle #1 injured?
(20 Characters)
If the driver was injured, briefly describe the injuries:
Passengers in Vehicle #1 (If any)
Name
Address
City
State
Zip
Phone
Brief desc. of injuries (if any)
Areas of Damage to the Vehicle #1
Driver rear panel
Pass. Front Fender
Rollover
Frontend
Other
Pass. rear panel
Trunk
Interior
Rearend
No Damage
Driver Front Fender
Hood
Mechanical
Tires
Pass. Right Side
Driver Left Side
Contact for Repairs
*Name
*
Direct Phone
Cell Phone
Towing company name
Towing company phone
Preferred repair city for vehicle #1
Utah Department of Transportation
T-840a
Print Form
Accident/Incident Report
Vehicle #1 is the state vehicle, any other vehicle(s) involved are #2. Fields marked with
*
are required. If more than 2 vehicles are involved
separate
please attach a
piece of paper with all the information.
Report Date
*Emp. Drivers Lic. #
*UDOT Veh. Vin. #
*Date of Accident
*Time of Accident (HH:MM)
Date & Time Unknown (old damage, not hit & run)
*Road on which accident happened, with nearest intersection
*
Was vehicle off the paved surface when the accident happened?
Nearest City of Accident
*State
Zip Code
*Weather Conditions
*Road Surface Conditions
Estimated Speed (use numbers)
Responding Police Dept.
Police Case #
*Make
*Model year
*License plate #
*Vehicle #
*Emp. ID #
*Operator
Job title
*Region Address
*City
Zip
*State
*Work Phone (Emp.)
*Employee Gender
Cell Phone (Emp.)
Was the operator of vehicle #1 wearing a seatbelt?
Was the operator of vehicle #1cited?
Was the operator of any other involved vehicles cited?
Was the operator of vehicle #1 talking on a cell phone?
Were there any passengers in vehicle #1?
Was the operator of vehicle #1 injured?
(20 Characters)
If the driver was injured, briefly describe the injuries:
Passengers in Vehicle #1 (If any)
Name
Address
City
State
Zip
Phone
Brief desc. of injuries (if any)
Areas of Damage to the Vehicle #1
Driver rear panel
Pass. Front Fender
Rollover
Frontend
Other
Pass. rear panel
Trunk
Interior
Rearend
No Damage
Driver Front Fender
Hood
Mechanical
Tires
Pass. Right Side
Driver Left Side
Contact for Repairs
*Name
*
Direct Phone
Cell Phone
Towing company name
Towing company phone
Preferred repair city for vehicle #1
Utah Department of Transportation
T-840a
Accident/Incident Report
Other Vehicles Involved # 2(If any)
Vehicle #2 Drivers Name
Address
City
*State
Zip
Phone
Drivers Lic. #
Exp. Date
Insurance Co.
Policy #
Year
Make
Model
Plate #
Injuries
*State
Driver rear panel
Pass. Front Fender
Rollover
Front End
Other
Pass. rear panel
Trunk
Interior
Rearend
No Damage
Driver Front Fender
Hood
Mechanical
Tires
Pass. Right Side
Driver Left Side
Witnesses to Accident (If any). Must be individuals not involved in the accident. Could be bystanders, etc.:
Name
Address
City
State
Zip
Phone
*Describe the Accident
*Accident Type
One other vehicle:
Two or more vehicles:
Fixed object:
Personal injury:
Fatal:
Property Damage?
*
Do you feel this accident was Preventable or Non-Preventable on your part?
Preventable, Why?
Non-Preventable, Why?
(Safety Office Use Only)
Region Ref#:
Fleet Ref#:
Oracle Ref#:
State Risk Ref#:
Employee Signature
Date
Supervisor Signature
Date

Download Form T-840A Accident/Incident Report - Utah

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