Roadside Safety Incident Reporting Tool Roadside Safety Incident Reporting Tool A form to report any incidents of road safety such as near misses, individuals not slowing down, or flying debris that posed a danger. Which agency are you reporting from? (can select only one) Fire or Fire Rescue EMS (Emergency Medical Services) Police Sheriff Bylaw Enforcement Peace Officer Public Works Roadside Assistance, Towing/Recovery Construction Private Corporation Construction Municipal Employee Construction Provincial Employee Other (describe) Other (describe) Date of Incident (format: yyyy-mm-dd) * Time * 121234567891011 : 0030 AMPM Location * Urban Town/Village Rural Address of Incident Address of Incident Address 1 Address 1 Address 2 Address 2 City/Town City/Town Province Province Postal Postal Address of Incident Location Description (can select more than one) * Shoulder Gravel road Asphalt top, no lines Two-way, single lane, secondary highway (with lines) Four-lane major highway On / Off Ramp Intersection Median Overpass Underpass Off Road Provide any additional information, to best of your ability, the exact location or nearest landmark where the incident occurred. (comment field)Provide any additional information, to best of your ability, the exact location or nearest landmark where the incident occurred. (comment field) If this was an emergency response scenario, what type of emergency response were you providing at the time of the incident? (can select more than one) You can skip this question if Not Applicable (was not an emergency response scenario) * Crash Scene Debris removal Directing Traffic Disabled Vehicle EMS Medical Assist Fire Scene (Wildfire) Other Law enforcement activity Traffic Stop Other (describe) Other (describe) Number of emergency vehicles on scene: * Zero, you were first on scene 1 2 3 4 5 and above (approx. number) 5 and above (approx. number) If this was NOT an emergency response was it: Road side maintenance i.e. grass cutting, installing signs, washing signs etc. Directing traffic (Special event) Road construction zone with speed reduction in effect. Other (describe) Other (describe) N/A (Skip Question) Road Conditions: What were the road conditions like at the time of the incident? (can select more than one) Ice covered Snow covered Excess water (Rain) Flooded Clear / Dry Visibility Conditions: What were the visibility conditions like at the time of the incident? (multiple choice, can select more than one with exception of Clear / day) Clear / day (cannot not select this in conjunction with another below) Dark / night (with street lights) Dark / night (no street lights) Rain Snow Fog Smoke conditions or wildfire Storm / Extreme Weather Conditions (Snow Blizzard) Storm / Extreme Weather Conditions (Thunderstorm, Heavy Rain, Hail) Distance of Visibility: Was the incident: (multiple choice, can select more than one) On a straight road Blind curve Hill Visibility obstructed by other means (e.g., another large vehicle) Comment:Comment: Safety Measures in Place: Were there any traffic management or safety measures in place at the scene? (multiple choice, can select more than one) Full traffic incident management in the area Traffic Cones Flares Personnel directing traffic Blocking apparatus (fire) Arrow boards Advanced warning signage Electronic message board Flashing blue lights OtherOther Type of incident: Was the incident related to passing motorists: (can select more than one) Not slowing down Flying debris Other hazards (use comment field below) CommentComment Response of the Motorist(s): How did the motorist(s) involved in the incident react? (multiple choice, can select more than one. Accelerated Ignored signs Unsafe breaking Unsafe lane change OtherOther Outcome of the incident; Was anyone injured as a result of the incident? Yes No CommentComment Was a WCB Claim Filed Yes No CommentComment Was an Occupational Health and Safety Report filed? Yes No CommentComment Were there any damages to: Equipment Vehicles No damages CommentComment Was an insurance claim filed for: Personal injury Equipment damages Vehicle damagesVehicle damages No claim filed CommentsComments Additional Observations: Are there any other observations or details you think are important to share about the incident? * I confirm that the information provided in this form is accurate and truthful to the best of my knowledge. Request for Contact Information: To maintain the highest level of accuracy and consistency in our reporting, we may occasionally require further clarification on the information provided. In such rare instances, we kindly request your contact details to facilitate this process. Please rest assured, your contact information will be used solely for the purpose of clarifying data and will be handled with the utmost confidentiality in compliance with our privacy policies. * I consent to provide my contact information for the purposes outlined above. Name Name First First Last Last Email Department / Organization Submit If you are human, leave this field blank.