Public Incident/Accident Report

This is NOT a police or DMV report.

This form is for incidents involving a county vehicle, property, employee or operation.

Please ll out this form as completely as possible. Attach additional sheets if necessary to provide all details

and a complete explanation. Attach any supporting documents, photos, damage estimates, etc. For questions

regarding completing report, call Risk Management at 503-655-8459 or email [email protected].

If this report concerns a motor vehicle accident, please complete required information on page 2.

Return this form to:

Address _________________________________________________________________________________________________

City ____________________________________________________________ State ____________ Zip _________________

Phone ____________________________ m Home m Work m Cell Email __________________________________

Incident/Accident Date ________________________________ Time __________ m a.m. m p.m.

Location where incident occurred ________________________________________________________________________

Type of damage _________________________________________________________________________________________

Extent of injury ___________________________________________________________________________________________

Witness name _____________________________________________________ Phone ______________________________

Witness name _____________________________________________________ Phone ______________________________

Person(s) injured ________________________________________________________________________________________

Year ______________ Make _____________________________ Model ___________________________________________

License Plate # ________________________ If county-owned, vehicle number _________________________________

Driver Name ____________________________________________ Driver License # ________________________________

Owner’s Name ___________________________________________________________________________________________

Address _________________________________________________________________________________________________

City ____________________________________________________________ State ____________ Zip _________________

Phone ____________________________ m Home m Work m Cell

Damage to vehicle _______________________________________________________________________________________

Passengers in vehicle ____________________________________________________________________________________

Seat belts in use and secured? Driver m Yes m No Passengers m Yes m No

License Plate # ________________________ If county-owned, vehicle number _________________________________

Driver name ____________________________________________ Driver license # _________________________________

Owner’s Name ___________________________________________________________________________________________

Address _________________________________________________________________________________________________

City ____________________________________________________________ State ____________ Zip _________________

Phone ____________________________ m Home m Work m Cell

Damage to vehicle _______________________________________________________________________________________

Passengers in vehicle ____________________________________________________________________________________

Seat belts in use and secured? Driver m Yes m No Passengers m Yes m No

Photos m Yes m No

Law enforcement at scene?

m Yes m No

Jurisdiction __________________

Was a citation issued to you?

m Yes m No

This form is for incidents involving a county vehicle, property, employee or operation.