Near Miss/Crash Reporting Form
Your Insights Drive Action – Help Us Push for Stronger Work Zone Protections
Full Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Contractor Name
Incident Date
-
Month
-
Day
Year
Date
Incident Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Was a police report filed?
Yes
No
Crash or Near Miss? Please select one of the following:
Crash
Near Miss
Were workers present at the time of the incident/was it an active work zone?
Yes
No
What part of the work zone did the incident occur?
Advance warning area (tells traffic what to expect ahead)
Transition area (moves traffic out of its normal path)
Buffer area (provides protection for traffic and workers)
Work area (space set aside for workers, equipment and material storage)
Termination area (lets traffic resume normal driving)
Incident Description
Submit
Should be Empty: