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INCIDENT, NEAR.MISS AND LOSS-REPORT <br /> (HSE AUTO 1PRO <br /> PE <br /> RTY) <br /> LJ <br /> � <br /> Stantec F e <br /> Use one of layouts below or draw plan(separate sheet). If any street is more than two-lane or is one Way only, please indicate. <br /> marks, road signs,direction of movement and any relevant details. <br /> ' ion. Show skid ma 9 <br /> Illustrate position of cars at the time of collas P <br /> VEHICLE IDENTIFICATION " <br /> S FOR STANTEC - <br /> NUMBERS.FOR THIRD PARTIES <br /> �� INDICATE <br /> I DIRECTIONS <br /> ---- -----------------------r'-- <br /> ------------ -T-- ! <br /> SHOW LABEL EACH <br /> STOP OR SLOW SIGNS. STREET <br /> r---------------- i <br /> i <br /> VEHICLES <br /> Stantec(S) f Vehicle No. 1 Vehicle No.2 <br /> i DIRECTION <br /> HEADED <br /> SIDE OF STREET <br /> RATE OF SPEED r <br /> u <br /> BLEW HORN <br /> GAVE SIGNAL F1 <br /> WEATHER ❑Clear El Cloudy ❑ Fog ❑ Raining ❑Snowing ❑ Other describe: <br /> LIGHT ❑ Daylight El Dusk ❑ Darkness with street or highway ❑ Lighted ❑ Not Lighted <br /> k <br /> Paved <br /> El Gravel ❑Wet Dry ❑ Muddy ❑ Icy ❑ Snowy ❑ Loose material on surface <br /> ROAD CONDITIONS <br /> ❑ Defective shoulder ❑ Holes/deep ruts El Other <br /> ! <br /> HSE=620 Incident,Near Miss&Loss Report Rev. 10-08 y Page 6 of 6 <br /> I{ �t <br /> 1f <br /> k <br />