Road Traffic Accident Form.XLS

							             TESLA OFFSHORE                                                                                             FORM:   RTA1

                                                   ROAD TRAFFIC ACCIDENT REPORT
                                                              Page 1                                              SEQ. No:




             Date of Accident:                                  Day of Week:                            Time (local):              am/pm
             Place of Accident:
             City:                                              State:                             Country:
             IF ON PROJECT ACTIVITY
             Project Number:                                                                 Client:
             Project Title:                                                              End Client:

             COMPANY DRIVER
             Name:                                                                        Employer:
             Residential Address at date of accident:




             Drivers Licence No.:                                              Country of Issue:
             Expiry Date:                                                      Was driver wearing seat belt?
             Was driver injured?                        If 'YES", was taken to :
             If attended by doctor, give doctor's name:

             COMPANY VEHICLE
             Reg. No.:                                         Make:                                   Model:
             Age of Vehicle:                    years         Owner:
             If towing trailer, give details:
             Give names of passengers: Front:
             Rear:
             Describe Damage to Co. vehicle:




             OTHER DRIVER
             Name:
             Residential Address:




             Drivers Licence No.:                                              Country of Issue:
             Expiry Date:
             Was driver injured?                        If 'YES", was taken to :
             If attended by doctor, give doctor's name:

             OTHER VEHICLE
             R  N                                              M k                                     M d l




Road Traffic Accident Form Page 1                                                                                                          Rev 10/95
             TESLA OFFSHORE                                                                                    FORM:     RTA2
                                               ROAD TRAFFIC ACCIDENT REPORT
                                                          Page 2                                              SEQ. No:



             OTHER INJURED
             Did any other persons claim to be injured?          YES/NO **   If "YES", give:
             Name:                                               Age:        Sex:              Nationality:
             Address:
             Name:                                               Age:        Sex:              Nationality:
             Address:
             Name:                                               Age:        Sex:              Nationality:
             Address:

             WITNESSES
             Name:                                                           Phone No.:
             Address:


             Name:                                                           Phone No.:
             Address:


             Name:                                                           Phone No.:
             Address:




             DESCRIPTION OF ACCIDENT




             Attach separate sheet if more space is needed

             WEATHER/ROAD CONDITIONS
             Describe Weather:
             What type of road surface?                                             Dry or Wet?
             How many lanes in each direction?
             Describe visibility:

             OTHER INFORMATION
             In what direction was Company vehicle travelling?
             In what direction was other vehicle travelling?
             Did other vehicle give warning signal?                          If "YES", what kind?
             What lights did other vehicle have on?




Road Traffic Accident Form Page 2                                                                                               Rev 10/95
             TESLA OFFSHORE                                                                               FORM:    RTA2
                                               ROAD TRAFFIC ACCIDENT REPORT
                                                          Page 3                                        SEQ. No:



             DIAGRAM OF ACCIDENT SCENE
             Indicate the positions, directions and speeds of each vehicle involved, immediately prior to, and at the time
             of impact. Indicate the positions of any injured pedestrians and witnesses. Show the positions of any damaged
             property.




                                                            INDICATE NORTH
             REPORTED TO
             To which authority was this accident reported?
             Date?                                        Time?                            Where?

             Was it reported to the Client?:                        If so, to whom, and when?



             OTHER REPORTS
             Indicate whether any other reports apply to this incident:



             FOR SAFETY COORDINATOR'S USE
             Indicate actions taken to avoid repeat incident:




             Report compiled by:                            Date:                                     For Safety Co-ordinator Use
             Signature:                                    Place:                                        CLASSIFICATION

             Report Reviwed by                              Date:                  Sign:                Location




Road Traffic Accident Form Page 3                                                                                                   Rev 10/95