N.Y. Comp. Codes R. & Regs. tit. 17 § 990.20
NYS PUBLIC TRANSPORTATION SAFETY BOARD RAIL TRANSIT OPERATOR ACCIDENT REPORT
PROPERTY NAME: ________________________________________________________
ACCIDENT DATE _ / _ / _ TIME OF ACCIDENT ____ ......................................................................................................
ACCIDENT CRITERIA: _ COLLISION _ GRADE CROSSING _ DERAILMENT...................................................................................................
_ EVACUATION _ MULTIPLE INJURY _ FATALITY ...................................................................................................
LOCATION OF ACCIDENT:
LINE_LANDMARK_CITY_COUNTY _ _____________________________________________
TRAIN OPERATOR INFORMATION:
NAME: __________ DOB: _ / _/ _
TRAIN VEHICLE INFORMATION:
TRAIN # _______ CAR OR ENGINE # ________
OTHER VEHICLE INFORMATION:
YEAR _ MAKE/MODEL ________
WITNESS NAME, PHONE #: WITNESS NAME, PHONE #: WITNESS NAME, PHONE #: ACCIDENT DESCRIPTION: LAW ENFORCEMENT AGENCY INVESTIGATING ACCIDENT: _ ____________________________________________
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PROPERTY OFFICIAL FILING THIS REPORT
TITLE
PHONE #
DATE OF REPORT: ________
NYS PUBLIC TRANSPORTATION SAFETY BOARD TRANSIT BUS OPERATOR ACCIDENT REPORT
PROPERTY NAME: ____________________________________________________________
ACCIDENT DATE _ / _ / _ TIME OF ACCIDENT ___.............................................................................
ACCIDENT CRITERIA:
_ MECHANICAL FAILURE _ FIVE OR MORE INJURIES _ FATAL _ FIRE
LOCATION OF ACCIDENT:
STREET _ CITY _____________________________________________
COUNTY ____________
BUS DRIVER INFORMATION:
NAME: __________ DOB: _ / _ / _
DRIVER'S LICENSE ID# _______ STATE OF REGISTRATION _______
PROPERTY VEHICLE INFORMATION:
YEAR __ MAKE/MODEL _______
# OF OCCUPANTS IN VEHICLE AT TIME OF ACCIDENT _
OTHER VEHICLE INFORMATION:
YEAR _ MAKE/MODEL ________
# OF OCCUPANTS IN VEHICLE AT TIME OF ACCIDENT _
WITNESS NAME, PHONE #: WITNESS NAME, PHONE #: WITNESS NAME, PHONE #: ACCIDENT DESCRIPTION: LAW ENFORCEMENT AGENCY INVESTIGATING ACCIDENT: _ _________________________________________
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PROPERTY OFFICIAL FILING THIS REPORT
TITLE
PHONE #
DATE OF REPORT: ________
N.Y. Comp. Codes R. & Regs. Tit. 17 § 990.20