Driver Distraction Incident Report Form
Please complete this form to report a driver distraction incident. All fields are required for a comprehensive report.
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident (Address or Nearest Landmark)
*
Type of Distraction
*
Please Select
Mobile phone use
Eating or drinking
Adjusting controls (radio, GPS, etc.)
Talking to passengers
External distraction (e.g., roadside event)
Other
Vehicles Involved (List all vehicles, if applicable)
*
Brief Description of the Incident
*
Contributing Factors (Select all that apply)
*
Fatigue
Poor visibility/weather
Heavy traffic
Speeding
Impaired driving (alcohol/drugs/medication)
Other
Immediate Action Taken
*
Please Select
Pulled over safely
Warned driver
Assisted injured parties
No action taken
Other
Were any injuries reported?
*
Yes
No
Unknown
Were authorities notified?
*
Yes
No
Your Name and Contact Information (optional)
Submit Report
Should be Empty: