Notification of Vehicle Incident Form - Policy • Berwick Church of Christ Inc.

All vehicle incidents must be reported to the Safety Contact Person within 24 hours of an incident occurring.

Refer to the Transport Safety Policy and Driver's Declaration Form distributed alongside this Form and others on the church website - www.berwickchurch.org.au/policies.

Driver's Details

Driver's First Name *

Driver's Mobile Number *

Driver's Vehicle Make & Model *

Driver's Last Name *

Driver's Email Address *

Driver's Vehicle Registration No. *

Details of the Incident

Date the incident happen? *

Time: (24 hour clock) *

Where did the incident happen? (Location including building number, street name and suburb as applicable) *

Where were you travelling to? *

Where were you travelling from? *

What happened? Provide a description of events leading up to the incident and the incident itself. *

Was there significant damage to property? *

Was an alcohol and/or drug test conducted on the driver. *

Was there a loss of control of the vehicle? *

If yes, what were the test results?

Were any persons seriously or fatally injured as a result of the incident? *

Please provide the full name, age, and contact details of those seriously/fatally injured.

Declaration & Signature

I declare that:

The information provided in this notification are true and correct.
I understand that it is an offence to provide any false and misleading information and that penalties apply.

Electronic Signature *

I agree that by checking this box, I am electronically signing this declaration.

Please add the date this notification was completed. *