8182F Idaho Uniform School Bus Accident/Injury Report Form

NON-INSTRUCTIONAL OPERATIONS8182FPage 1 of 5IDAHO UNIFORM SCHOOL BUS ACCIDENT/INJURY REPORT FORMSchool DistrictContractorDate Of Accident Day Time □ a.m. □ p.m.Location (City) (County) Police Report No._____________(attach copy to this report)Driver's Name _________________________ Age ____________ Male FemaleDriver License No.Bus NumberBus V.I.N. ___________________________________(REQUIRED)Citation Issued: Bus Driver Yes No Other Vehicle Driver Yes NoDriver Training: Pre-service Training Yes No In-service Training Yes NoYears Driving Bus: 1 or less 1 - 2 2 - 5 5-10 Over 10Number Of Accidents In Last Three Years: Drivers Lap Belt In Use Yes No(while driving bus only)Chassis Manufacturer: Body Manufacturer: Model Year:Bus Type: A B C D Other Rated Seating Capacity:Wheelchairs:Passengers on Bus:Part I - School Bus Physically Involved In Accident1. Type Of Accident (Enter Only One Response) Between Motor Vehicles Fixed Object Pedalcycle Pedestrian Train Other Collision2. Specify Fixed Object which most caused accident (ex.: parked vehicle, utility pole, guardrail, tree, etc.)3. Did Accident Result In? Fatality Possible Injury (Minor) Property Damage Only Non-incapacitating Injury (Moderate)($750.00 Or More) Incapacitating Injury (Serious)4. Manner Of Collision Between Vehicles Or Objects: Angle Head-on Rear-end Other5. Bus Direction Analysis:Collision With Pedestrian Intersection Non-Intersection Bus Going Straight Bus Turning Right Bus Turning Left Bus Backing Other Action (Specify)Collision With Other Vehicle Intersection Non-Intersection Entering same direction, both moving Entering opposite direction, both moving Entering at angle, both moving One vehicle stopped Other ActionIdaho State Department of EducationP.O. Box 83720, Boise, Idaho 83720-0027, 208-332-6851Page 1 (rev. 02/00)

NON-INSTRUCTIONAL OPERATIONS8182FPage 2 of 5All Other Collisions Intersection Non-intersection Fixed Object Other Vehicle or Train Pedalcycle Other Object, AnimalNoncollision Intersection Non-intersection Overturn OtherOn-board AccidentsNumber of students injured by falls, striking stanchions, etc., when bus is in motion and not involved in other listedaccident types above. Accident must be due to sudden movement of the bus.6. Point Of Impact (Enter As Many As Applicable)7. Contributing Circumstances (Enter As Many As Applicable):Roadway Defective Surface (e.g., potholes) Slippery Inoperative Traffic Signal Obstructed View (e.g., tree, fence, sign, etc.) OtherVehicle Defect Tires Brakes Lights Steering No Vehicle Defect OtherDriver's Actions: (Mark appropriate boxes, as many as applicable, under bus driver and other driver columns. Whataction was each driver taking when the accident occurred.)Driver Action Bus Driver Other DriverSpeedingRight Of Way - Failed To YieldPassed Stop SignDisregarded Traffic SignalDrove Left Of CenterImproper OvertakingMade Improper TurnFollowed Too CloselyBackingSudden MovementNo Improper Action8. Total Number of Lanes on Roadway9. Posted Speed LimitIdaho State Department of EducationP.O. Box 83720, Boise, Idaho 83720-0027, 208-332-6851Page 2 (rev. 02/00)

NON-INSTRUCTIONAL OPERATIONS10. Approximate Speed of The Bus8182FPage 3 of 5Idaho State Department of EducationP.O. Box 83720, Boise, Idaho 83720-0027, 208-332-6851Page 3 (rev. 02/00)

NON-INSTRUCTIONAL OPERATIONS11. School Bus Use At Time Of Accident (enter as many as applicable): Regular Route Special Needs Use Other Field/Activity Trip Deadheading (no passengers)8182FPage 4 of 512. Condition Of Road At Time Of Accident (enter as many as applicable - Circle the response that most contributed tothe accident.): Dry Under Repair Holes or Ruts Wet Icy Snow Packed Muddy Other (Specify)13. Light Conditions (enter one response): Dawn Daylight Dusk Dark, Artificially Illuminated Dark, Not Artificially Illuminated14. Weather Conditions (enter as many as applicable): Clear Raining Snowing Smog/Smoke Sleeting Fog Dust Other (Specify)PART II - DESCRIPTION OF ACCIDENT(attach police report)Complete the following diagram showing direction and positions of vehicles involved, clearly designating the point ofimpact. Use additional space if needed.Idaho State Department of EducationP.O. Box 83720, Boise, Idaho 83720-0027, 208-332-6851Page 4 (rev. 02/00)

NON-INSTRUCTIONAL OPERATIONS8182FPage 5 of 5PART III - INJURY TALLY SHEETINDICATE BY NUMBERTHE SCHOOL TRANSPORTATION - RELATED PERSONNEL INJUREDIndicate by * if off bus injuries occurred in Loading/Unloading zones.AGEUNDER 556789101112131415161718OVER 18DRIVEROTHERSTOTALSKILLEDM FSERIOUS MODERATE MINOR ON theBusInjuries occurred:OFF theBusDescribe the seating positions of passengers with severe and fatal injuries: ___________________________________How many pupils in above table were killed by the bus they ride: ___________________________________________________________________________________________________________________________________________Report reviewed by:Transportation Supervisor (required) Driver (required) DateIdaho State Department of EducationP.O. Box 83720, Boise, Idaho 83720-0027, 208-332-6851Page 5 (rev. 02/00)