Numbness Details

In order to document an accident, it is necessary to fill out an accident report form. The purpose of this form is to gather information about the accident so that it can be analyzed and used to improve safety conditions. There are many different types of accident report forms, so it is important to know which one needs to be filled out for the particular accident. The form must be filled out as accurately as possible, and should include information such as the date and time of the accident, the location, who was involved, and what happened. A thorough description of the accident is also required. Any pictures or videos taken at the scene should be included as well. Once the form has been completed, it should be submitted to a supervisor for review.

You can find details about the type of form you want to submit in the table. It can show you the span of time you will need to finish accident report form, what parts you will have to fill in, and so forth.

QuestionAnswer
Form NameAccident Report Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesIrritability, headrest, citations, Disturbances

Form Preview Example

ACCIDENT REPORT FORM

NAME

 

 

 

AGE

DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

DATE OF ACCIDENT/INJURY

 

TIME

LOCATION

 

 

 

 

 

 

 

 

 

 

 

Please describe how accident/injury happened:

Please describe in detail your present symptoms:

Please describe symptoms immediately following accident/injury:

EMPLOYMENT

Yes

No

Describe (if any)

Have you lost any days of work? Please list dates.

 

Date of return to work fully.

 

Prior to the accident were you able to work on an equal

 

basis with others your age?

 

Are any of your activities restricted?

 

AUTO ACCIDENT ONLY

 

Were you aware of the oncoming accident?

 

Were you wearing a seatbelt? Type?

 

Were weather conditions a factor? Please describe.

 

Were you moving at the time of the accident? Speed?

 

If stopped, was your foot on the brake?

 

Was the other vehicle moving at the time of the accident?Speed

 

Were traffic citations issued? To whom?

 

Were you knocked unconscious? If so, how long?

 

Were you hospitalized? How did you get there?

 

Was your torso or head turned at the time of impact? How?

 

Did you have symptoms prior to the accident?

 

Where were you seated in the vehicle?

 

What is the cost damage to the vehicle you were in?

 

Where was the vehicle struck?

 

Please list the year, make & model of the care you were in.

 

Please list any previous auto accidents.

 

How far was the top of headrest from the top of your head?

 

Please list the year, make & model of the other vehicle.

 

Please check which car parts broke: Rt-Lt side windows Windshield Steering wheel Front/back seat

On what part of the car did the following body parts hit: Head:

 

 

 

Chest:

 

Lt/Rt shoulder:

 

Lt-Rt arm:

 

Lt-Rt hip:

 

 

 

 

 

 

 

 

 

 

 

Lt-Rt leg:

 

 

Lt-Rt knee:

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

For proper handling of your claim please fully complete.

Check symptoms you have noticed since Accident:

Headache

Constipation

Fainting

Chest Pain

Neck Pain

Diarrhea

Loss of Balance

Depression

Neck Stiffness

Dizziness

Loss of Taste

Loss of Strength

Sleeplessness

Nausea

Loss of Smell

Ringing in Ears

Mid Back Pain

Head Feels Heavy

Cold Hands

Light Sensitivity

Low Back Pain

Numbness in Legs

Cold Feet

Clumsiness

Arm Pain

Numbness in Arms

Loss of Memory

Face Flushed

Leg pain

Numbness in Toes

Disorientation

Cold Sweats

Nervousness

Numbness in Fingers

Unclear Thinking

Upset Stomach

Tense Muscles

Difficulty Breathing

Visual Disturbances

Fever

Irritability

Fatigue

Difficulty Swallowing

 

Your Auto Insurance:

 

 

Driver’s Auto Insurance (if different):

Company Name:

 

 

 

Company Name:

 

 

 

Address:

 

 

 

Address:

 

 

 

City, State, Zip:

 

 

City, State, Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Company Phone Number:

 

 

Company Phone Number:

 

 

 

Policy Number:

 

 

Policy Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claim No. (if known):

 

 

 

Claim No. (if known):

 

 

 

Your Health Insurance:

 

 

Other Parties Auto Insurance:

 

 

Company Name:

 

 

 

Company Name:

 

 

 

Address:

 

 

 

Address:

 

 

 

City, State, Zip:

 

 

City, State, Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Company Phone Number:

 

 

Company Phone Number:

 

 

 

Policy Number:

 

 

Policy Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claim No. (if known):

 

 

 

Your Attorney (If Any):

 

 

Doctors or Hospitals Consulted:

Name:

 

 

 

Name:

 

 

 

Address:

 

 

 

Address:

 

 

 

City, State, Zip:

 

 

City, State, Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone Number:

 

 

 

Dates of Treatment:

 

 

 

Signature:

 

 

 

Date:

 

 

 

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