Vehicle Collision Report

This form is used by City of St. Catharines employees to report any collision involving a City vehicle with another vehicle or building/object. If an employee is injured, you must also submit an Employee Incident Report.

Once this report is submitted, it will go directly to the Equipment Operator Trainer, Human Resources Health and Safety Consultant and Manager of Realty and Insurance Services.

Location of Collision

Date of Collision mm/dd/yyyy

Time of Collision (24 Hour)

City Vehicle

Vehicle Number

Vehicle Type

Vehicle Year and Make

VIN #

Plate Number

Driver's Name

Driver's License Number

Passenger's Name (if applicable)

Vehicle Speed at Time of Collision (km/h)

Driver's Address

Describe Damage to City Vehicle

Describe damage to City building/property (if applicable)

Please upload a drawing of the accident and up to 5 pictures of the damage, if available.

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

How the damage was caused and describe activity at time of collision (e.g. plowing, driving to site, etc.)

Name of Injured Employee, if any

Nature of Injury, if any

Was First Aid Performed?

Yes

No

Not Applicable

Was Employee Taken to Hospital?

Yes

No

Ambulance

Not Applicable

Name of Additional Injured Employee, if any

Nature of Injury of Additional Injured Employee, if any

Was First Aid Performed?

Yes

No

Not Applicable

Was Employee Taken to Hospital?

Yes

No

Ambulance

Not Applicable

Other Vehicle

Vehicle Type

Vehicle Year and Make

Plate Number

VIN Number

Insurance Co. and Policy Number

Driver's Name

Driver's License Number

Driver's Address

Phone Number

Owner's Name

Approximate Vehicle Speed (KM/h)

Name of Injured Person, if any

Nature of Injury, if any

Were additional vehicles involved? (if yes, please attach collision reports below)

Yes

No

Witnesses

Witness #1 Name

Witness #1 Phone Number

Witness #1 Address

Witness #2 Name

Witness #2 Phone Number

Witness #2 Address

Conditions at Time of Collision

Road Conditions

Weather Conditions

Were Police Called

Yes

No

Did Police Attend the Scene

Yes

No

Was a Police Report Completed

Yes

No

Is the Police Report Attached

Yes

No

Name of Officer

Badge Number

Report Number

Did you attend a Collision Reporting Centre?

Yes

No

Collision Reporting Centre report attached?

Yes

No

Date of attending Collision Reporting Centre mm/dd/yyyy

Time of attending Collision Reporting Centre (24 Hour)

If available, upload Police report or Collision Reporting Centre report.

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Report Completed by

Date Completed

The personal information collected on this Incident Form is collected under authority of Municipal Act. This information will be used for the purposes of documenting vehicle collision incidents and any necessary follow-up as may be required in accordance with said legislation. Questions about the collection of personal information should be directed to the Office of the City Clerk, or reached at 905-688-5601 ext. 1569 or privacy@stcatharines.ca.

Questions specific to the Municipal Freedom of Information and Protection of Privacy Act, can be directed to the Office of the Clerk (905) 688-5601 ext. 1569 or privacy@stcatharines.ca.