North Carolina Department of Transportation Citizen Incident Statement

Form 141
Rev 12/1/2005
North Carolina Department of Transportation
Citizen Incident Statement
This form is designed to assist in reporting an incident resulting in damage or injury that involved the North Carolina Department
of Transportation.
GENERAL INFORMATION:
(Please fill out General Information for either vehicle incident or property incident)
1. Your Name: _______________________________________________________________________________
2. Your Address: ______________________________________________________________________________
City: _________________________________ State: _____________ Zip Code: _________________________
3. Telephone: Business: (_______)____________________ Home: (______)_____________________________
4. Date of Incident: _____________ Time: _________ Location: ________________________________________
__________________________________________________________________________________________
5. State Agency Involved in Incident: _______________________________________________________________
6. State employee you consider responsible for the

Incident:____________________________________________________________
7. Address: ___________________________________________________________________________________
8. Explain in your own words how you were injured or damaged and in what way you believe the State employee was responsible.
Form 141
Rev 12/1/2005
INCIDENT INVOLVING A MOTOR VEHICLE: (Please fill out only if incident involved a motor vehicle)
9. Private Vehicle Involved in Incident:
Make: ____________________________ Model: ___________________________ Year: _______________________
License Number: __________________________________ State: _________________________________________
Driver: __________________________________________ Age: __________________________________________
Owner of Vehicle: ________________________________________________________________________________
Insurance Company and Policy Number: _______________________________________________________________
Speed of Vehicle at the time of the incident: _____________________________________________________________
Has the vehicle been repaired? ________________________________________________________________________
If the vehicle has been repaired, state place where it was repaired: _____________________________________________
Cost of Repair: ________________ Have the Repairs been paid for? _________________________________________
If the repairs were paid for, who paid for them? __________________________________________________________
10. The damages consist of the following: __________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
11. State Vehicle:
Agency: _______________________________________ Operator: _________________________________________
Address: _______________________________________ Make of Vehicle: ___________________________________
Model: ________________________________________ Year: ____________________________________________
License No.: ___________________________________ Speed of Vehicle: ___________________________________
If State Vehicle, was it a truck, state: Was it loaded _____ with what _________________________________________
How high was it loaded? _________________________ Was it covered? _____________________________________
12. Injuries:
Name: __________________________ Address: _______________________________________________________
Name: __________________________ Address: _______________________________________________________
Name: __________________________ Address: _______________________________________________________
Name: __________________________ Address: _______________________________________________________
13. Nature of Injuries: ________________________________________________________________________________
_______________________________________________________________________________________________
Form 141
Rev 12/1/2005
14. Doctor(s): ______________________________________________________________________________________
Hospital(s): _____________________________________________________________________________________
Date of Treatment: _______________________________________________________________________________
15. If there were any witnesses to the accident, please list names below and their addresses:
Name: __________________________ Address: _______________________________________________________
Name: __________________________ Address: _______________________________________________________
Name: __________________________ Address: _______________________________________________________
16. Investigation Officer: _____________________________________________________________________________
Department: ____________________________________________________________________________________
17. Show how incident occurred by using one of these diagrams:
IMPORTANT: Please fill in diagram showing position of automobile and injured person (or other vehicle with which insured
vehicle collided) with direction in which both were proceeding.
Your Car Other Car Trailer Motorcycle Bus Truck
1 2 B T
Indicate Points of Compass

(N,E,S,W)
Form 141
Rev 12/1/2005
INCIDENT INVOLVING PROPERTY DAMAGE:
(Please fill out only if incident involved property damage other than a vehicle)
18. Property Involved in Incident:
Address: ______________________________________________________________________________________
City: ________________________________ State: __________________ Zip Code: _________________________
19. Date of Incident: ____________________ Time: _______________
20. State Agency Involved: ___________________________________________________________________________
21. State Employee you consider responsible for the incident:

______________________________________________________________
22. Address of State Employee: _______________________________________________________________________
23. State Project Number: ___________________________________________________________________________
24. Contractor: ____________________________________________________________________________________
Provide any additional comments or attach pictures related to the incident.
Date of Report: ______________________________ Signature: ________________________________________________

North Carolina Department of Transportation Citizen Incident Statement

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Form 141

1. Your Name: _______________________________________________________________________________

2. Your Address: ______________________________________________________________________________

City: _________________________________ State: _____________ Zip Code: _________________________

3. Telephone: Business: (_______)____________________ Home: (______)_____________________________

4. Date of Incident: _____________ Time: _________ Location: ________________________________________

5. State Agency Involved in Incident: _______________________________________________________________

6. State employee you consider responsible for the

9. Private Vehicle Involved in Incident:

Make: ____________________________ Model: ___________________________ Year: _______________________

License Number: __________________________________ State: _________________________________________

Driver: __________________________________________ Age: __________________________________________

Owner of Vehicle: ________________________________________________________________________________

Insurance Company and Policy Number: _______________________________________________________________

Speed of Vehicle at the time of the incident: _____________________________________________________________

Has the vehicle been repaired? ________________________________________________________________________

10. The damages consist of the following: __________________________________________________________________

11. State Vehicle:

Agency: _______________________________________ Operator: _________________________________________

Address: _______________________________________ Make of Vehicle: ___________________________________

Model: ________________________________________ Year: ____________________________________________

License No.: ___________________________________ Speed of Vehicle: ___________________________________

How high was it loaded? _________________________ Was it covered? _____________________________________

Name: __________________________ Address: _______________________________________________________

Name: __________________________ Address: _______________________________________________________

Name: __________________________ Address: _______________________________________________________

Name: __________________________ Address: _______________________________________________________

13. Nature of Injuries: ________________________________________________________________________________

14. Doctor(s): ______________________________________________________________________________________

Date of Treatment: _______________________________________________________________________________

Name: __________________________ Address: _______________________________________________________

Name: __________________________ Address: _______________________________________________________

Name: __________________________ Address: _______________________________________________________

16. Investigation Officer: _____________________________________________________________________________

17. Show how incident occurred by using one of these diagrams:

Your Car Other Car Trailer Motorcycle Bus Truck

Indicate Points of Compass

18. Property Involved in Incident:

City: ________________________________ State: __________________ Zip Code: _________________________

19. Date of Incident: ____________________ Time: _______________

20. State Agency Involved: ___________________________________________________________________________

21. State Employee you consider responsible for the incident:

22. Address of State Employee: _______________________________________________________________________

23. State Project Number: ___________________________________________________________________________

24. Contractor: ____________________________________________________________________________________

Provide any additional comments or attach pictures related to the incident.

Date of Report: ______________________________ Signature: ________________________________________________

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City: ___________________________ State: _ Zip Code: ___________________

3. Telephone: Business: (_) Home: ()_________________

4. Date of Incident: _________ Time: _ Location: ____________________________________

Make: ______________ Model: _ Year: ___________

License Number: State: _______

Driver: Age:

Agency: _ Operator: ___

Address: _____ Make of Vehicle: _

Model: Year: ____

License No.: _ Speed of Vehicle: _

How high was it loaded? _ Was it covered? _____________

Name: Address: _____________________________

Name: Address: _____________________________

Name: Address: _____________________________

Name: Address: _____________________________

Name: Address: _____________________________

Name: Address: _____________________________

Name: Address: _____________________________

City: ______ State: Zip Code: _

19. Date of Incident: ______ Time: _

Date of Report: Signature: __________________