DOA-FM-012 Form PDF Details

In the realm of fleet management and operational safety, accurate and timely reporting of accidents, incidents, or events involving vehicles is crucial. The DOA-FM-012 form serves as a comprehensive tool for this purpose, providing a structured format for collecting vital information immediately following such occurrences. It covers various aspects from basic driver and vehicle details, specifics about the accident or incident including the location, road, and weather conditions, to information about any other parties involved. Additional sections on the form guide drivers on documenting damages to the involved vehicles, details of any injuries, witness accounts, and the responses from emergency or law enforcement agencies who attended the scene. Beyond capturing the immediate facts, the form also prompts consideration of the preventability of the incident and recommendations for future avoidances, thereby contributing to the broader goal of improving organizational safety and minimizing risks. The form operates under regulatory authority and is a key element in adhering to legal and procedural requirements, emphasizing the importance of responsible vehicle operation and incident management within organizations.

QuestionAnswer
Form Name DOA FM 012 Form
Form Length 2 pages
Fillable? Yes
Fillable fields 87
Avg. time to fill out 15 min
Other names WV, 5A-1-2, DOA-FM-012, 5A-3-53

Form Preview Example

Fleet Driver Report of Accident/Incident/Event

Accident/Incident Date:

 

 

Accident/Incident Time:

 

 

Report Type:

Accident

Incident

Event

Report Type: Initial

Interim

Final

 

 

 

Spending Unit Driver Information (You may complete this section at your office)

 

 

Name:

 

 

 

 

 

Date of Birth:

 

 

 

 

Job Title:

 

 

 

 

Assigned Department/Division:

Work Phone Number:

 

Driver’s License Number:

 

Expiration Date:

Date Last Completed Defensive Driver

Seat Belt On?

 

 

 

 

 

 

Training?

 

 

Yes

No

 

 

 

Spending Unit Vehicle Information (You may complete this section at your office)

 

 

Vehicle Make:

 

 

 

 

Vehicle Model:

 

Vehicle Number:

 

 

Vehicle License Plate Number:

 

 

Vehicle Color:

 

Odometer at time of accident / incident:

Describe Damages to Spending

 

Minor

 

Moderate

 

Major

 

 

Unit Vehicle:

 

 

 

 

 

 

 

 

 

 

Is this a rental

Yes

 

 

 

No

Is this a Personally Owned Vehicle?

Yes

No

vehicle?

If YES, provide name of rental company

 

 

 

 

 

 

 

 

 

Accident Details (to be completed at the scene of accident/incident)

 

 

 

Location of

Address:

 

 

City:

State:

 

Zip Code:

 

Accident/Incident

 

 

 

 

 

 

 

 

 

 

Road Conditions:

Dry

Wet

Ice

Snow

Weather Conditions:

Overcast

Rain

Snow

Fog

Traffic

 

 

 

 

How fast were you

 

Estimated speed of

 

 

Conditions:

Light

Heavy

driving - MPH?

 

other vehicle:

 

 

 

Other Driver / Registered Ownter / Vehicle Information (To be completed at the scene of accident/incident)

Driver’s Name:Date of Birth:Driver’s License State: Expiration Date: No.:

Home Phone Number:

 

 

Work Phone Number:

 

 

Number of Passengers in Other Vehicle:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver’s Address

Street:

 

 

City:

 

State:

 

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Registered Owner of Other Vehicle

Home Phone Number:

 

 

Work Phone Number:

(If different from Driver)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Owner’s Address

Street:

 

 

City:

 

State:

 

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Party’s

Insurance Co:

 

 

Address:

 

Phone Number:

 

Policy Number:

Insurance Info

 

 

 

 

 

 

 

 

 

 

 

 

 

Vehicle

 

 

Vehicle

 

 

 

Year:

 

 

 

 

Color:

 

 

Make:

 

 

Model:

 

 

 

 

 

 

 

 

 

 

 

Extent of Damages to Other

Minor

 

 

 

Moderate

 

 

 

Major

Vehicle:

 

 

 

 

 

 

 

 

 

 

 

 

 

License Plate of Other

Plate

Number:

 

 

State:

 

 

Describe Damages

to Other Vehicle:

Vehicle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WITNESSES (To be completed at the scene of accident/incident)

 

 

 

Name

 

 

Address

 

 

Phone Number

Name

Address

Phone Number

Name

Address

Phone Number

DOA-FM-012 Page 1 Revised (24 March 2011)

Enabling statute: WV Code §5A-1-2(f) and §5A-3-48 through 5A-3-53.

Regulatory authority: Code of State Rules 148 CSR 3.

 

Passengers in Spending Unit Vehicle (You may complete this section at your office)

Name:

 

Address:

Phone Number:

Describe Injury (If Applicable)

 

 

 

 

 

Name:

 

Address:

Phone Number:

Describe Injury (If Applicable)

 

 

 

 

 

 

 

 

Passengers in Other Vehicle (To be completed at the scene of accident/incident)

Name:

 

Address:

Phone Number:

Describe Injury (If Applicable)

 

 

 

 

 

Name:

 

Address:

Phone Number:

Describe Injury (If Applicable)

 

 

 

 

 

 

 

 

 

 

 

Describe How This Accident/Incident Occurred

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was There Any Additional, Non-Vehicle Property Damage?

 

 

 

Check & Name Agencies Responding to the Accident/Incident Scene

 

 

 

Fire

 

Ambulance

 

 

State Police

City Police

 

 

 

 

County Sheriff

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was a Report Made?

 

Yes

 

No

Accident Report Number:

 

 

 

 

 

Investigating Agency:

 

 

 

 

Name

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date & Time 911 was Notified of

 

 

 

Date:

 

 

 

 

 

Time:

 

 

 

Accident/Incident

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Spending Unit Driver

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To Be Completed by Spending Unit Driver Supervisor

 

 

 

 

 

 

Supervisor’s Name:

 

 

 

 

 

Phone Number:

 

 

 

 

 

 

In Your Opinion, Could This

Accident/Incident Have Been Prevented?

 

Yes

 

No

If YES, explain:

 

Recommendations:

Signature of Supervisor

DOA-FM-012 Page 2 Revised (24 March 2011)

Enabling statute: WV Code §5A-1-2(f) and §5A-3-48 through 5A-3-53.

Regulatory authority: Code of State Rules 148 CSR 3.

Date

How to Edit DOA-FM-012 Form Online for Free

By adhering to these steps, you can guarantee that the DOA-FM-012 form is completed thoroughly and correctly, creating a trustworthy document for managing the incident's aftermath.

1. Accident/Incident Details

Write the date and time of the accident or incident at the top of the form. Select whether the report is for an accident, incident, or event and specify if this is the initial, interim, or final report.

2. Spending Unit Driver Information

Complete the section titled "Spending Unit Driver Information." Here, you must input the driver's name, date of birth, job title, assigned department/division, work phone number, driver's license number, and expiration date.

Indicate whether the driver had completed defensive driving training and whether a seat belt was worn during the incident.

3. Spending Unit Vehicle Information

In the "Spending Unit Vehicle Information" section, record the make, model, and number of the vehicle involved, along with its license plate number, color, and odometer reading at the time of the incident.

Describe the extent of the damages (minor, moderate, major), and specify if the vehicle was a rental or personally owned.

4. Accident Details

Document the location of the accident, including the address, city, state, and zip code. Note the road and weather conditions, traffic conditions, your driving speed, and the estimated speed of any other vehicle involved.

5. Other Driver and Vehicle Information

Fill in details about the other driver(s) involved in the incident, including their name, date of birth, driver’s license number, state of issuance, expiration date, phone numbers, and address. Include their information if the vehicle's registered owner differs from the driver.

Also, details of the other vehicle’s make, model, year, color, and the extent of damages are needed.

6. Witness and Passenger Information

If there were witnesses or other passengers, record their names, addresses, and phone numbers. Describe any injuries if applicable.

7. Describe the Accident/Incident

Provide a thorough description of the accident or incident, aiming to capture as many details as possible to aid future investigations or insurance claims.

8. Additional Information and Official Use

Indicate whether there was any non-vehicle property damage, list any responding agencies, and state whether an official report was made. This section may also include a field for the investigating agency's details.

9. Supervisor Section

The spending unit driver’s supervisor should review the form and may add their insights about the preventability of the incident and any recommendations for future prevention.

The spending unit driver and the supervisor must sign and date the form.

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