Work Zone Mobility and Safety Program

Kansas Department of Transportation
Report of Accident Investigation

A. Location and Time of Accident


City (If Appropriate):


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

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

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