Incident Report Form

Name *

Phone Number *

Email *

Incident Date *

Incident Time *

Incident Location *

Type of Incident (multi‐select or single choice) *

If Other Selected Put Your Details Here

Vehicle Make *

Vehicle Model *

Registration *

Licence Number *

Sweeper / Vehicle Information (if known)

Operator or contractor name

Vehicle ID or unit number

Colour, make/model (if known)

Registration or fleet number

Persons Involved / Witnesses

People involved

Name and contact info (optional/witness)

Relationship (e.g. pedestrian, motorist, business owner)

Description of Incident (long text) *

Consequences / Damage

Was anyone injured?

Yes

No

If yes: describe injuries, treatment needed or sought

Was property damaged?

Yes

No

If yes: describe damage (vehicle, fence, gutter, wall, etc.)

Was cleanup required?

Yes

No

Evidence Upload

Upload photos or video

Choose File

Evidence Upload

Upload documents (e.g. repair estimates, witness statements, police report)

Choose File

Drivers Licence *

Front and Back

Choose File

Did you call emergency services?

Yes

No

(If yes, which: police, ambulance)

Did you notify company / contact authority?

Follow-Up / Request

What resolution would you like? (e.g. repair, inspection, changes to schedule)

Additional comments

13. Declaration and Signature

I declare the information is true to the best of my knowledge *

Tick

Signature *

Date Submitted *

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Sweeper / Vehicle Information (if known)

Persons Involved / Witnesses

Consequences / Damage

Follow-Up / Request

13. Declaration and Signature

contact info

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