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FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      System Form 9 Complete Information on Next Page POLICE REPORTPolice ReportYes FORMCHECKBOX No FORMCHECKBOX If yes, which agency FORMTEXT      Case No. FORMTEXT      Phone Number FORMTEXT      PURPOSE OF TRIPWas System Vehicle in Emergency Response? FORMCHECKBOX  FORMCHECKBOX Yes NoIf Yes: Were Lights Activated  FORMCHECKBOX   FORMCHECKBOX Yes NoIf Yes: Was Siren Activated FORMCHECKBOX   FORMCHECKBOX Yes NoBrief Explanation of Trip Purpose (Why were you driving the vehicle):  FORMTEXT      NARRATIVE OF INCIDENT Briefly describe how incident occurred (Driver s Statement) Use separate page if necessary FORMTEXT      DIAGRAM Use separate page if necessary C O M P L E T EINCIDENT TYPEIndicate NorthCheck Applicable Box or Boxes FORMCHECKBOX Backed Into By OV FORMCHECKBOX Property Hit by OV FORMCHECKBOX Backed Into OV FORMCHECKBOX Ran Red Light/Stop Sign FORMCHECKBOX Blow Out FORMCHECKBOX Rear-End Collision FORMCHECKBOX Changing Lanes Collision FORMCHECKBOX Slid on Ice/Rain FORMCHECKBOX Collision with Animal FORMCHECKBOX Struck Road Hazzard FORMCHECKBOX Collision with Fixed Object FORMCHECKBOX Collision with Parked Vehicle FORMCHECKBOX Collision with Bicyclist or Pedestrian FORMCHECKBOX Failed to Control Speed FORMCHECKBOX Failed to Yield Right of Way FORMCHECKBOX Fatigued or Fell Asleep FORMCHECKBOX Fire FORMCHECKBOX  Theft FORMCHECKBOX Vandalism FORMCHECKBOX Glass/Windshield FORMCHECKBOX Hail FORMCHECKBOX Wind FORMCHECKBOX Head-on Collision FORMCHECKBOX Hit and Run Collision FORMCHECKBOX Jack-Knifed FORMCHECKBOX Load Not Secured FORMCHECKBOX Loading/Unloading FORMCHECKBOX Other FORMCHECKBOX Opened Door Into OV FORMTEXT      Driver s Signature FORMTEXT      Date FORMTEXT       PLEASE NOTE: You must notify Risk Management by creating a new incident in Origami, including a scan of completed MVAR, within 48 hrs. For further information or support, please contact your Vehicle Coordinator or System Risk Management. 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