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City of Hoover Accident/Incident Information and Employee Statement GENERAL INFORMATION ABOUT THE ACCIDENT/INCIDENT When did the accident/incident occur? Date: Location/Address of the accident/incident: Description of City Vehicle - Make: Chevy Model: Tag City Vehicle Number: Vehicle Identification Number: Name of the Investigating Police Officer: Case Number INFORMATION ABOUT WITNESSES TO THE ACCIDENT/INCIDENT INFORMATION ABOUT WITNESS INFORMATION ABOUT WITNESS name Name: address Address: city state zip City: State: Zip: Phone # Phone # EMPLOYEE STATEMENT What do you feel was the cause of this accident/incident? How could this accident/incident be avoided in the future, if possible? Employee's Signature Print Employee's Name Date of Statement Reviewing Supervisor's Signature Print Reviewing Supervisor's Name Date of Review ATTACH ADDITIONAL SHEETS IF NECESSARY Form 11050 (r4/17/02) ---PAGE BREAK--- Instructions for completing this form are also provided (Employee Statement Instructions) on the Shared Drive.