1. REPORT NO.

2.PROVINCIAL OFFICE

2. POLICE STATION

REPUBLIC OF THE PHILIPPINES PHILIPPINE NATIONAL POLICE TRAFFIC ACCIDENT REPORT FORM
9.ACCIDENT SEVERITY F. S. M. D. FATAL ACCIDENT SERIOUS INJURY ACCIDENT MINOR INJURY ACCIDENT PROPERTY DAMAGE ONLY

4.REGIONAL OFFICE

5.NUMBER OF VEHICLES INVOLVED 6.NUMBER OF DRIVER CASUALTIES 7. NUMBER OF PASSENGER CASUALTIES 8. NUMBER OF PEDESTRIAN CASUALTIES 15. JUNCTION TYPE 1.Not at junction 5. 2. 3. 4. 20. WEATHER 1. 2. 3. 4. 5. 6. 7. Fair Rain Wind Smoke Fog Dazzle Storm 6. 7. Railway 8.Other 21.LIGHT 1. 2. 3. 4. Daylight Dawn/dusk Night (lit) Night (unlit) 16. TRAFFIC CONTROL

10. MONTH DATE 13. DAY OF THE WEEK 14. TIME (MILITARY TIME)

11. DAY

12. YEAR

17.COLLISION TYPE

18.MOVEMENT

1. Head On 6. Hit Object in Road 1. 1-way 1.None 2. Rear End 7. Hit Object Off Road 2. 2-way 2.Centerline 3. Right Angle 8. Hit Parked Vehicle 3.Pedestrian Crossing 4. Side Swipe 9. Hit Pedestrian 19. SEPARATION 4.Schoool Crossing 5. Overturned Vehicle 10. Hit Animal 5.Polic Controlled 1. Median 6.Traffic Lights 11. Other. 2. No Median 7.Stop Sign 8.Give Way 9.Other 22. ROAD CHARACTER 23. SURFACE 24.SURFACE TYPE 25. MAIN CAUSE CONDITION 1. Straight + Flat 1. Concrete 1. Vehicle Defect 2. Curve only 1. Dry 2. Asphalt 2. Road Defect 3. Incline only 2. Wet 3. Gravel 3. Human Error 4. Curve +incline 3. Muddy 4. Earth 4. Other 5. Bridge 4. Flooded 6. Crest 5. Other 28. HIT & RUN 1. Yes 2. NO 29. LOCATION TYPE 1. Urban Area 2. Rural Area

26. ROAD CLASS 1. National 2. Provincial 3. city 4. Municipal 5. Barangay

27. ROAD REPAIRS 1. Yes 2. No LOCATION

Name of City/Town/Barangay ..Distance.(km/m) Landmark 1.. Distance.(km/m) Name of Road.Between JUNCTION ACCIDENT ONLY Landmark 2Distance.(km/m)

Name of SECOND ROAD..Distance.(km/m) COLLISSION DIAGRAM SKETCH Mark the position and direction of each vehicle and details of the road layout at the site of the accident.

LOCATION SKETCH MAP Show site in relation to prominent landmarks such as KM posts or Major intersections. Mark distances to the landmarks.

POLICE DESCRIPTION OF ACCIDENT

WITNESSES 1.Name.............................................................. ...................... Address.. 2.Name... Address.... INVESTIGATING OFFICER Name/Rank...... SUPERVISING OFFICER

DRIVER STATEMETNS Driver 1 ...... ...... Driver 2...... ......

Name/Rank. .... ACTION TAKEN RECOMMENDATION STATUS OF CASE

Additional form(s) will be needed if there are more than 2 vehicles, more than 4 passenger casualties or more than 2 pedestrian casualties. Fill in the report no, provincial office, police station and dates and fix form together securely 1.REP NO. VEHICLE 1 2.PROV OFFICE 30.VEHICLE PLATE NUMBER 3.POL STN 4.REG OFFICE DRIVER 1 ADDRESS 32.ENGINE NUMBER OR/CR DETAILS MODEL/YEAR 35.VEHICLE MANEUVER 7.Bus 8. Truck(Rigid) 9.Truc(artic) 10. Van 11. Animal 12. Other 37. DIRECTION 1.North 2. South 3. East 4. West 1.Left Turn 7.Overturn 13.Parked on Road 2.Right turn 8.going Ahead 14. Other 3. U-Turn 9. Reversing 4. Cross Traffic 10. Sudden Start 5. Merging 11. Sudden Stop 6. Diverging 12. Parked off Road 38.VEHICLE DEFECT 1. None 5.Fires 2. Lights 6.Multiple 3. Brakes 7.Other 4. Steering LICENSE NUMBER LICENSE TYPE 40.DRIVER SEX 41. DRIVER AGE 43. DRIVER ERROR 6. No signal 7. Bad Overtaking 8. Bad Turning 9. Using Cell Fone 10. Other 45.SEAT BELT/HELMET 1. Seat belt/Helmet Worn 2. Not worn 3. Not worn correctly EXPRIY DATE 42. DRIVER INJURY 1.Fatal 2. Serious 3.Minor 4. Not injured NAME DATE

31.OWNERS NAME & ADDRESS CHASSIS NUMBER 33.INSURANCE MANUFACTURER (MAKE) 34.VEHICLE TYPE 1.bicycle 2. Pedicab 3. Motor cycle 4. Tricycle 5. Car 6. Jeepney 36. LOADING 1. LEGAL 2. Overloaded 3. Unsafe Load

1.None 2. Fatigued/Asleep 3. Inattentive 4. Too Fast 5. Too Close 39. VEHICLE DAMAGE 44. ALCOHOL/DRUGS 1. None 5. Left 2. Front 6. Roof 1.Alcohol Suspected 3.Rear 7. Multiple Drugs Suspected 4. Right 8. Other 2.Not Suspected

VEHICLE 2

30.VEHICLE PLATE NUMBER

DRIVER 2 ADDRESS

NAME

31.OWNERS NAME & ADDRESS CHASSIS NUMBER 33.INSURANCE MANUFACTURER (MAKE) 34.VEHICLE TYPE 1.bicycle 2. Pedicab 3. Motor cycle 4. Tricycle 5. Car 6. Jeepney 36. LOADING 1. LEGAL 2. Overloaded 3. Unsafe Load VEHICLE 3 7.Bus 8. Truck(Rigid) 9.Truc(artic) 10. Van 11. Animal 12. Other 37. DIRECTION 1.North 2. South 3. East 4. West 32.ENGINE NUMBER OR/CR DETAILS MODEL/YEAR 35.VEHICLE MANEUVER 1.Left Turn 7.Overturn 13.Parked on Road 2.Right turn 8.going Ahead 14. Other 3. U-Turn 9. Reversing 4. Cross Traffic 10. Sudden Start 5. Merging 11. Sudden Stop 6. Diverging 12. Parked off Road 38.VEHICLE DEFECT 1. None 5.Fires 2. Lights 6.Multiple 3. Brakes 7.Other 4. Steering

LICENSE NUMBER LICENSE TYPE 40.DRIVER SEX 41. DRIVER AGE 43. DRIVER ERROR 6. No signal 7. Bad Overtaking 8. Bad Turning 9. Using Cell Fone 10. Other 45.SEAT BELT/HELMET 1. Seat belt/Helmet Worn 2. Not worn 3. Not worn correctly EXPRIY DATE 42. DRIVER INJURY 1.Fatal 2. Serious 3.Minor 4. Not injured

1.None 2. Fatigued/Asleep 3. Inattentive 4. Too Fast 5. Too Close 39. VEHICLE DAMAGE 44. ALCOHOL/DRUGS 1. None 5. Left 2. Front 6. Roof 1.Alcohol Suspected 3.Rear 7.Multiple Drugs Suspected 4. Right 8. Other 2.Not Suspected DRIVER 3 ADDRESS NAME

30.VEHICLE PLATE NUMBER

31.OWNERS NAME & ADDRESS CHASSIS NUMBER 33.INSURANCE MANUFACTURER (MAKE) 34.VEHICLE TYPE 1.bicycle 2. Pedicab 3. Motor cycle 4. Tricycle 5. Car 6. Jeepney 7.Bus 8. Truck(Rigid) 9.Truc(artic) 10. Van 11. Animal 12. Other 32.ENGINE NUMBER OR/CR DETAILS MODEL/YEAR 35.VEHICLE MANEUVER 1.Left Turn 7.Overturn 13.Parked on Road 2.Right turn 8.going Ahead 14. Other 3. U-Turn 9. Reversing 4. Cross Traffic 10. Sudden Start 5. Merging 11. Sudden Stop 6. Diverging 12. Parked off Road

LICENSE NUMBER LICENSE TYPE 40.DRIVER SEX 41. DRIVER AGE 43. DRIVER ERROR 1.None 2. Fatigued/Asleep 3. Inattentive 4. Too Fast 5. Too Close 44. ALCOHOL/DRUGS 6. No signal 7. Bad Overtaking 8. Bad Turning 9. Using Cell Fone 10. Other 45.SEAT BELT/HELMET EXPRIY DATE 42. DRIVER INJURY 1.Fatal 2. Serious 3.Minor 4. Not injured

36. LOADING 1. LEGAL 2. Overloaded 3. Unsafe Load

37. DIRECTION

38.VEHICLE DEFECT

1.North 1. None 5.Fires 1.Alcohol Suspected 1. Seat belt/Helmet Worn 2. South 2. Lights 6.Multiple Drugs Suspected 2. Not worn 3. East 3. Brakes 7.Other 2.Not Suspected 3. Not worn correctly 4. West 4. Steering PASSENGER CASULATIES COMPLETE 1 FULL LINE for each passenger casualty. See Reference boxes below

39. VEHICLE DAMAGE 1. None 5. Left 2. Front 6. Roof 3.Rear 7. Multiple 4. Right 8. Other