Kansas Department of Transportation
Report of Accident Investigation

A. Location and Time of Accident

Route:

City (If Appropriate):

County:

Project Number:

Reference Number:

Type of Improvement:

KDOT Investigating Personnel:

B. Time of Events

Time of Accident:

• Date:
• Hour:

Time KDOT Notified:

Time Traffic Resumed Normal Operation:

Length of Repair Time:

C. Summary of Accident (Use additional sheets if necessary)

D. Vehicle Involved

	Veh. 1	Veh. 2	Veh. 3
Type of Vehicle
Direction of Travel
Driver Action
Apparent Driver Condition

E. Injuries or Medical Attention Required

Yes or No:

Number Injured:

Type of Injuries:

Drivers	1	2	3
Age
Sex

Rev. 8-95, D.O.T. Form No. 290