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2. Incident Date and TIme
   Incident Date and TIme

   Incident Date and TIme
3. County Vehicle Number
5. Employee Name
6. Employee Department
8. Job Title
9. Email Address
11. Work Address
12. Phone Number
16. Supervisor's Name
17. Date and Time Reported to Supervisor
    Date and Time Reported to Supervisor

    Date and Time Reported to Supervisor
19. Date and Time Reported to Fleet Management (520.432.9380)
    Date and Time Reported to Fleet Management (520.432.9380)

    Date and Time Reported to Fleet Management (520.432.9380)
20. Time and Date Reported to Risk Management (520.432.9830)
    Time and Date Reported to Risk Management (520.432.9830)

    Time and Date Reported to Risk Management (520.432.9830)
22. Photos taken at scene

    1. Yes
    2. No
23. Photographer/Agency
27. Type of Incident

    1. Collision
    2. Property Damage
    3. Vandalism
    4. Theft
    5. Other
28. Vehicle Action

    1. Backing up
    2. Going straight ahead
    3. Turning Right
    4. Turning Left

    1. Stationary
    2. Parked
    3. Other
30. Employee Vehicle Speed (estimated)
31. Other Party Estimated Speed
32. Was Anyone Injured

    1. Yes
    2. No
34. Did Police and/or Fire Respond

    1. Yes
    2. No
35. Police Report Number
36. Property Damage

    1. None
    2. Other Vehicle/Equipment
    3. Utility
    4. Mailbox
    5. Other
38. If Underground Utility, Bluestake Number
39. Date Utility Notified
41. Description of Incident in Detail
43. Describe Vehicle/Equipment Damage
45. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
47. Electronic Signature
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field