Ohio



3194685-20002500Accident DetailsDate of AccidentClick or tap to enter a date.Time?AM?PMODOT Vehicle Project #VIN #Road ConditionWeatherNumber of Passengers on Board the Vehicle at the time of the AccidentWhere any of the passengers injured??Yes?NoIf yes, how many of the passengers?Name of driver operating the vehicle at the time of the accidentIs the driver up to date on the following requirements? (check all that apply)?DRIVE and/or Wheelchair Securement (PAT) Training?Bloodborne Pathogen Training?Drug Awareness Training?Frist Aid?CPR?The driver is over 18 years old and has a valid driver’s license?Accident/Incident Procedures TrainingPlease provide a description of the accident including how the accident occurred and which party was at fault. Click or tap here to enter text.ACCIDENT/INCIDENT REPORT FORMAll ODOT subrecipients are required to contact the Program Coordinator within 48 hours of the occurrence of any Serious Accident/Incident. The agency will provide ODOT with this completed form detailing the accident. If the incident does not meet the definition of a serious accident/incident, then subrecipients are not required to submit a report to ODOT.Agency Name:Federal ProgramChoose an item.Please check all that applied to this incident to qualify it as a “Serious Accident/Incident”?A fatality occurred at the scene or confirmed within 30 days of the incident?There was an injury requiring immediate medical attention away from the scene for one or more persons?Property damage at the scene was equal to or exceeding $25,000?A disabled vehicle was towed from the scene?An evacuation occurred for life safety reasonsA Serious Accident/Incident is defined as a safety or security accident or incident resulting in one or more of the following conditions: a fatality occurring at the scene or confirmed within 30 days of the incident; an injury requiring immediate medical attention away from the scene for one or more persons; property damage at the scene equal to or exceeding $25,000 or the towing of any disabled vehicle from the scene; and/or an evacuation for life safety reasons.If this vehicle is deemed a total loss by insurance, you will be required to complete the following steps:Notify the ODOT Program Coordinator within 48 hours of receiving notification that the vehicle is totaled. Provide a copy of the insurance check issued by your insurance agency via email to the ODOT Program Coordinator80% of the depreciated value of the vehicle is considered federal investment and must be reinvested into a replacement vehicle to meet program objectives until the vehicle is disposed from the program. Replacement Vehicles must be ordered through ODOT and the State Term Contract. Any costs in excess of the insurance check amount will need to be covered with additional local share. If the accident qualifies as a Serious Accident/Incident (see above checklist) update the number of reportable incidents in the Statistics report submitted to ODOT. If the vehicle will be repaired and placed back into service, you must notify the ODOT Program Coordinator once the vehicle is placed back in service. Program Coordinator Contact InformationSection 5311 – Rural Public Transit Program/JARCTodd BarstowTodd.barstow@dot.(614) 644 – 5754Section 5310 – Specialized Transit Program/New FreedomKierra BranchKierra.Branch@dot.(614) 387 – 5190 Section 5339 – Bus and Bus Facilities Alex EwersAlex.ewers@dot.(614) 728 – 5629 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download