Highway Incident Data Collection Form
Section 1: General Information
Date of accident:
Time of accident:
Location of accident:
Highway/Route:
Weather Conditions:
Clear
Rainy
Foggy
Other
Number of Vehicles Involved:
Section 2: Accident Details
Accident Type:
Select
Collision (Vehicle-Vehicle)
Collision (Vehicle-Pedestrian)
Rollover
Single Vehicle Crash
Cause of Accident:
Select
Speeding
Drunk Driving
Distracted Driving
Mechanical-Failure
Other (Specify)
Other Causes:
Vehicle Type(s):
Other Vehicles (if any):
Section 3: Casualties and Injuries
Total Number of Casualties:
Gender:
Select
Female
Male
Injury Severity:
Select
Fatal
Severe
Minor
None
Transported to Hospital:
Select
Yes
No
Section 4: Emergency Response
First Responders on Scene:
Select
Police
Ambulance
Fire Brigade
St. John Ambulance
St John Highway Volunteers
Other (Specify)
Response Time:
Section 5: Summary and Remarks
Summary Remarks and Care Given:
SUBMITTED BY ST JOHN VOLUNTEER FROM:
Trauma Clinic:
Select Trauma Clinic
Emali
Kinungi
Highway FirstAid Post:
Select FirstAid Post
Voi
Mtito Andei
Sultan Hamud
Machakis Junction
Limuru
Lari
Kijabe
Kinungi
Salgaa
Sachangwan
Mai Maiu
Katui
Awasi
Submit Report
