Accident Case #
REPORT OF PROPERTY DAMAGE BY BUS
A. Private Property Damage 1. Date___________ 2. Time____________ AM/PM 3. Day of Week______________
4. Type of route / trip being provided Regular Route ____ Extended Day____ Field Trip ____
5. Address where Property Damage is Located
6. Type of Property Damaged (for example: mailbox, fence, signs, etc.)
Amount of Damage to Property
1._____ None 2._____ Barely Visible (possible structural damage) 3. _____ Light Damage 4. ____ Heavy Damage 5. ____ Severe Damage
B. Bus 1. Bus # _________ 2. Driver's Field Coord. _________ 3. Assigned Bus # _________ 4. Spare Bus #_______
5. Driver's Name
6. Passengers Yes__________ No__________ 7. # Students ________________ 8. # of Other Passengers_______
C. Injuries 1. # Student(s) Injured_______ 2. Driver Injured Yes_____ No_____ Driver Transported Yes_____ No ______
3. # Students transported for medical attention _______ 4. Other passengers transported for medical attention _______
D. Citations 1. Name of Police Department ____________________________ 2. Police Officer ______________________
Driver of Bus Cited? ________ Yes _________ No
How did the accident happen? __________________________________________________________________________
E. Damage to Bus F. Location of Damage to the Bus 6. ______ Rear
1. ______ None 1. ______ Front 7. ______ Right Rear
2. ______ Barely Visible (possible structural damage) 2. ______ Right Front 8. ______ Left Rear
3. ______ Light Damage 3. ______ Left Front 9. ______ Right Rear Side
4. ______ Heavy Damage 4. ______ Right Front Side 10. ______Left Rear Side
5. ______ Severe Damage (vehicle towed from scene) 5. ______ Left Front Side 11. ______Midline
Road Paved ______ Unpaved ______ Gravel ______ Dirt ______ Mud ______ Wet ______ Icy ______ Dry ______
Describe Road Conditions_______________________________________________________________________________
Weather: Clear _____ Fog _____ Rain _____ Cloudy _____ Sleet _____ Snow _____ Ice _____ Dust _____ Bright Sun _____
Mechanic Dispatched to the Scene? ______ Yes ______ No
Name: ________________________________________________
Transportation Personnel Signature
Other Info.