DEPARTMENT OF THE NAVY UNITED STATES NAVY BAND 617 WARRINGTON AVE., SE

WASHINGTON NAVY YARD, DC 20374-5054

NAVBANDINST 11240.1E NB.OPS 15 Jun 2010

From: Commanding Officer/Leader, United States Navy Band

NAVY BAND INSTRUCTION 11240.1E

Subj: REGULATIONS FOR OPERATION AND MAINTENANCE OF MOTOR VEHICLES

Ref: (a) Navy Band Vehicle Procedures & Guide (b) NAVFAC P-300, (Naval Facilities Engineering Command

Publications Transmittal) (c) SECNAVINST 5100.13E, Navy and Marine Corps Tobacco

Policy (d) OPNAVINST 5100.12H, Navy Traffic Safety Program

Encl: (1) Motor Equipment Utilization Record (DD Form 1970) (2) Operator's Vehicle Inspection Sheet (Navy Band Form

4640/1) (3) Operator's Inspection Guide and Trouble Report

(NAVFAC 9-11240/13) (4) Operator's Report of Motor-Vehicle Accident (SF 91)

1. Purpose

2.

. To promulgate the regulations and restrictions governing the use of government vehicles, including Navy Band vans, passenger vans, and trucks. Also, to provide direction on the proper operation and maintenance of assigned transportation equipment.

Cancellation

3.

. NAVBANDINST 11240.1D.

Background

4.

. Navy Band is assigned custody of one 12-passenger, two 15-passenger vans, and five 2-ton trucks to assist in mission accomplishment. Navy Band is responsible for the proper use, maintenance and repair of these vehicles, and is financially responsible for any costs incurred upon termination of their use. Additionally, this activity is authorized to use vehicles provided by the Naval District Washington (NDW) Motor Pool as required.

Legal Restrictions. Title 5, U.S. Code, Section 78 contains restrictions on the official use of government vehicles and provides penalties for non-official use. Military personnel violating the above will be charged under the provisions of the

NAVBANDINST 11240.1E 15 Jun 2010

2

Uniform Code of Military Justice. The band is responsible for insuring that such use is for "official purposes." Administrative discretion, normally made by the Navy Band Operations Chief, will determine the guidelines which define official use. He/she will decide whether transportation essential to the successful operation of a task is "official." However, per reference (a), government vehicles are not in any case to be used to transport a Navy Band member to or from his/her place of residence. Note that reference (a) is available for review in the office of the Assistant Operations Chief, in each government vehicle Navy Band has custody of, and on the Admin Help Desk intranet website.

5.

a.

Regulations for Use of Equipment

Vehicle Requests. All vehicle requests will be made to the Navy Band Transportation Office in writing at least 24 hours prior to the requirement

b.

. The Operations Chief and/or Transportation Supervisor is/are responsible for evaluating and (dis)approving all requests.

(1) Every driver of a government vehicle is required to carry a Motor Equipment Utilization Record (MEUR) (DD Form 1970) (enclosure (1))

Required Forms

in the vehicle

(a) When completed, it contains a record of the route, destination, times of departure/arrival, load, odometer reading, and other information as needed.

. It authorizes the journey and is the driver's official authorization for operating the vehicle.

(b) Users of NDW Class "C" assigned vehicles shall submit the completed MEUR when the vehicle is returned to the Transportation Dispatcher, Building 400, Naval Station Anacostia (NAVSTA, ANA), Washington, DC.

(2) The driver is required to carry a Navy Band Operator's Vehicle Inspection Sheet (OVIS) (Navy Band Form 4640/1) (enclosure (2)). When this form is completed, it records the overall vehicle condition, availability of safety kit and spare tire, and statement of fuel purchase.

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(3) An Operator's Inspection Guide (NAVFAC 9-11240/13) (enclosure (3)) is to be filled out when turning the vehicle in for service and/or maintenance.

(4) A U.S. Government Motor Vehicle Operator's Identification Card, Form 346 (OF 346), is not required for military personnel operating a Government owned/leased vehicle under 10,000 pounds gross vehicle weight (GVW). This form is an issued document and not included as an enclosure. However, the driver must possess a valid state operator's license for the type and class of government vehicle being operated, per reference (b). Additionally, Form 346 is required when operating a Navy Band 2-ton truck.

(5) Per enclosure (4), the driver must ensure that an Operator's Report of Motor Vehicle Accident (Standard Form 91) is in the vehicle.

c. Transporting Civilian Personnel

d.

. Civilian personnel, including Navy Band dependents, will not be transported in government owned or leased vehicles without the approval of the Navy Band Operations Chief, Executive Officer/Assistant Leader, or Commanding Officer/Leader. Additionally, Navy Band owned or leased vehicles will not be loaned without prior permission of the above. This prohibition also applies to NDW buses/vans operated by NDW Motor Pool employees.

Alcoholic Beverages

e.

. The consumption of alcoholic beverages in a government vehicle is strictly prohibited. It is the responsibility of the assigned driver and the senior person in charge to ensure compliance.

Tobacco

6.

. Per reference (c), tobacco use is not permitted in government buses, vans, and shuttle vehicles.

a.

Equipment Operator's Responsibilities

Seat Belts. Per reference (c), DRIVERS WILL NOT MOVE THE VEHICLE UNTIL ALL

b.

PERSONS HAVE FASTENED THEIR SEAT BELTS. (Applies to trucks, vans, and cars.)

Daily Operations

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(1) The following services are to be performed daily before the vehicle is put into operation and are further clarified in reference (a):

(a) Check the fuel level. It is the driver's responsibility to ensure that the vehicle is adequately fueled. Allow plenty of time before departure to obtain fuel, if necessary. Additionally, prior to driving the vehicle, look underneath for any indication of fuel, oil, coolant, gear oil, or brake system leaks. Check the fuel, oil, and coolant levels.

(b) Sight inspect tires for proper inflation, unusual wear, and penetration of foreign objects. Make sure the brakes are in good working order and that the spare tire, tire changing equipment, and the road safety kit are present and in proper working condition.

(c) Test lights, horn, and windshield wipers for proper operation. Check vehicle equipment, mirrors, tail or side gates/doors.

(d) If inspection reveals that the vehicle is mechanically unsafe to operate, report the deficiencies to the Transportation Supervisor, Operations Chief or, if unavailable, the senior person in charge. It may be necessary to acquire another vehicle for the trip. Prompt reporting of problems will also speed up the necessary repairs.

(2) During operation, observe the dash indicators and warning lights, braking, steering, and performance of the engine and power-driven units. Report unusual noises or improper handling in the section marked "other" on the OVIS.

IT WILL BE THE OPERATOR'S RESPONSIBILITY TO CONVINCE HIM/HERSELF THAT THE VEHICLE IS IN SAFE OPERATING CONDITION.

(3) For safety reasons, operators of Navy Band vans and all trucks are required to take a passenger or second operator to use as a spotter when backing up the vehicle. Spotters must be used outside the vehicle whenever the vehicle is backing up.

(4) Upon return, the following services will be performed:

(a) The interior of the vehicle will be cleaned, and all tools and tire changing equipment properly stowed.

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(b) If the vehicle is equipped with air brakes, open the drain valve, drain off condensation, and close. Inspect all connections.

(c) Per reference (a) in case of a flat tire refer to section 4(c) of the Navy Band Vehicle Procedures Guide.

c.

(1) When driving an NDW vehicle, breakdowns must be reported by telephone to NAVFAC Maintenance, Building 400, Naval Station, Anacostia, at (202) 437-2594 during working hours. During non-working hours, contact Mr. Tarpley at 202-437-2052. A Public Works Department repair truck may be dispatched, or when it is deemed more economical, a commercial wrecker will be sent to tow the vehicle to the appropriate garage. If the breakdown is a result of an accident, appropriate action will be taken according to paragraph 7 of this instruction.

Procedure in Event of Breakdown

(2) Breakdowns of Navy Band vehicles will be reported immediately to the Navy Band Transportation Supervisor, Operations Chief, or Supply Chief, in that order.

d. Use of U.S. Government National Credit Cards

(1) Gasoline, regular unleaded (87 octane) or diesel fuel as required by manufacturer's specification

. A Wright Express Credit Card may be issued with the MEUR, Navy Band OVIS, and keys to the vehicle. Cards will be released on a custody receipt basis and must be returned immediately after each trip. Copies of sales receipts for all merchandise/services purchased must also accompany the card at the time of return. Additionally, the license number of the vehicle the card is used for, will be recorded on each receipt to track usage. If required, the following items and services may be procured:

(2) Lubricating oil

(3) Antifreeze products

(4) Battery service

(5) Tire repair (not replacement)

(6) Emergency replacement of light bulbs

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(7) Wiper arms and blades

(8) Minor

e.

emergency repairs

Emergency Repair Purchases

7.

. When an emergency situation cannot be met by the methods described in paragraphs 6.c. and 6.d., it may become necessary to purchase repairs with personal funds. A receipt itemizing the repairs will be submitted to the Navy Band Transportation Supervisor for approval and reimbursement on a case by case basis. You must contact Operations or Comptroller, and if necessary, leave a phone message, before proceeding with any purchase with the Wright Express Card other than fuel.

a. Per reference (c), drivers involved in accidents will:

Accidents

(1) Render appropriate assistance to the injured.

(2) Notify civil and military authorities.

(3) Complete the Operator's Report of Motor Vehicle Accident (Standard Form 91). In the event this form cannot be prepared by the driver, due to injury or death, the report will be completed by the next senior person directly responsible for the use of the vehicle.

(4) Comply, as required, with state and local laws, rules, and regulations governing the reporting of vehicle accidents. Official reports will be submitted through the defined channels to the appropriate claims officer. He/she will complete a review to ensure that the rights of the U.S. Government are not prejudiced by an admission of liability which will obligate the government.

(5) The driver will not express opinions (verbally or in writing) to claimants or their agents as to liability, investigation findings, or the possibility of a claim approval. He/she will not complete insurance company accident report forms. This procedure will afford the U.S. Government reasonable protection against claims filed in accordance with the Federal Tort Claims Act (28 U.S. Code, Sections 2671-2680).

NAVBANDINST 11240.1E 15 Jun 2010

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(6) The driver will not make official accident investigation reports (Standard Form 91) available to a claimant or to any individual or representative of any non-military organization.

(7) The driver will provide all concerned with contact information of the Transportation Supervisor 202-433-3676.

(8) As soon as possible, the driver will deliver the completed Standard Form 91 to the Navy Band Operations Officer and the Transportation Supervisor.

(9) Failure to report any accident/incident may result in disciplinary action.

b. Accident repair costs for each NDW vehicle in the custody of the Navy Band, involved in a "preventable" accident, will be borne by Navy Band.

8. Action

BRIAN O. WALDEN

. All personnel operating government vehicles will be completely familiar with the policies and procedures set forth in this instruction and comply accordingly.

Distribution: Electronic, via intranet

MOTOR EQUIPMENT UTILIZATION RECORD

1. DATE (YYYYMMDD) 2. TYPE OF EQUIPMENT 3. REGISTRATION NO./SERIAL NO. 4. ADMINISTRATION NO.

5. ORGANIZATION NAME

ACTION 9. TIME 10. MILES 11. HOURS

6a. FUEL b. OIL

7a. 1ST OPERATOR (Last Name, First, M.I.)

8a. OPERATOR'S SIGNATURE

a. IN

b. OUT

c. TOTAL

12a. REPORT TO (Last Name, First, M.I.)

13a. DISPATCHER'S SIGNATURE

7b. 2ND OPERATOR (Last Name, First, M.I.)

8b. OPERATOR'S SIGNATURE

12b. REPORT TO (Last Name, First, M.I.)

13b. DISPATCHER'S SIGNATURE

7c. 3RD OPERATOR (Last Name, First, M.I.)

8c. OPERATOR'S SIGNATURE

12c. REPORT TO (Last Name, First, M.I.)

13c. DISPATCHER'S SIGNATURE

7d. 4TH OPERATOR (Last Name, First, M.I.)

8d. OPERATOR'S SIGNATURE

12d. REPORT TO (Last Name, First, M.I.)

13d. DISPATCHER'S SIGNATURE

14. DESTINATION15. TIME

a. ARRIVE b. DEPART16. RELEASED BY (Signature) 17. REMARKS

(1) FROM

(2) TO

(3) TO

(4) TO

(5) TO

(6) TO

(7) TO

(8) TO

(9) TO

(10) TO

(11) TO

(12) TO

(13) TO

(14) TO

(15) TO

(16) TO

DD FORM 1970, NOV 1999 PREVIOUS EDITION MAY BE USED.

a. IN

b. OUT

c. TOTAL

a. IN

b. OUT

c. TOTAL

a. IN

b. OUT

c. TOTAL

INSTRUCTIONS

(17) TO

(18) TO

(19) TO

(20) TO

(21) TO

(22) TO

(23) TO

(24) TO

(25) TO

(26) TO

(27) TO

(28) TO

(29) TO

*1. Date. Enter the calendar date the equipment is to be used.

2. Type of Equipment. Enter the type of equipment as designated inthe equipment log.

3. Registration Number or Serial Number. Enter the equipment/registration number or serial number.

4. Administration Number. Enter the unit number or administrativenumber.

5. Organization Name. Enter the organization to which theequipment is assigned.

6. Fuel/Oil. Enter the amount of fuel (gallons) and/or oil (quarts)obtained for the equipment.

*7. Operator. Enter the name of the equipment operator.

8. Operator's Signature. The equipment operator (item 6) will entersignature immediately upon receipt of equipment.

*9. Time. Indicate time to the nearest 5 minutes using the 24-hourclock.a. In. Enter time equipment was returned from dispatch or use.b. Out. Enter the time the equipment was released for operation bythe dispatcher.c. Total. Enter total time the equipment was in the possession ofthe operator. Time is obtained by subtracting the time listed in "Out"line from that listed on the "In" line.

*10. Miles. Will be recorded to the nearest whole mile.a. In. The operator will enter the mileage reading when theequipment is returned. If odometer is inoperative, enter estimatedmileage.b. Out. The dispatcher will enter the mileage reading at the time ofdispatch.c. Total. Enter the difference between the "Out" and "In" mileage.

*11. Hours. Will be recorded to the nearest whole hour. On thoseitems which require servicing on an hourly basis and are notequipped with an hour meter, enter the estimated hours ofoperation. a. In. The operator will enter the hour meter reading uponcompletion of the equipment usage.b. Out. The dispatcher will neter the hour meter reading prior toequipment release.c. Total. Enter the total hours dispatched for operation.

*12. Report To. Enter the name of the individual to whom theoperator is to report.

13. Dispatcher's Signature. Self-explanatory.

14. Destination. Indicate each location at which a trip begins andends. Normally this starts from the equipment pool ("From" Line)and ends at the same place after one or more interveningdestinations.

*15. Time. All time will be recorded using the 24-hour clock,rounded off to the nearest 5 minutes.a. Arrive. Enter the arrival time at each destination.b. Depart. Enter the departure time from the motor pool and eachsucceeding location.

16. Released By. The person in charge of equipment on dispatchwill release by signing on the line indicating the destination wherethe equipment was released to the operator. Upon termination ofequipment used, but not moved, the person in charge will releasethe equipment by signing in the top block of this column.

17. Remarks. The remarks column will be used by the operator torecord unusual operation or abnormal occurrences during operation,or other information as directed.

*Items marked with an asterisk (*) have been registered in the DODData Element Program.

DD FORM 1970 (BACK), NOV 1999

14. DESTINATION15. TIME

a. ARRIVE b. DEPART16. RELEASED BY (Signature) 17. REMARKS

Navy Band SOY Grading Sheet Name Name NameCandidates Maximum points points points pointsPrimary duty 5Leadership 5Mentoring/Sailorization 5Military Bearing, Appearance, PRT 5Collateral Duties, command 5

Collateral Duties, unit 5Education 5Community Involvement 5Other qualifications:

Totals

Individual scoring1. Individual Board mbrs score candidates' records2. Candidate with highest score is ranked 1 3. Second highest score is ranked 2, and so on

Group scoring1. Give CMC your ranking order of candidates2. CMC adds board mbrs' rankings for each candidate3. Candidate with lowest ranking number is selected

MOTOR VEHICLEACCIDENT REPORT

INSTRUCTIONS: Sections I thru IX are filled out by the vehicle operator. Section X, Items 72thru 82c are filled out by the operator's supervisor. Sections XI thru XIII are filled out by anaccident investigator for bodily injury, fatality, and/or damage exceeding $500.

( )

DESCRIBE WHAT PEDESTRIAN WAS DOING AT TIME OF ACCIDENT (Crossing intersection with signal, against signal, diagonally; in roadway playing,walking, hitchhiking, etc.)

B

23. VEHICLE IS

Please read thePrivacy Act State-ment on Page 3.

6. EST. REPAIR COST

SECTION II - OTHER VEHICLE DATA (Use Section VIII if additional space is needed.)

SECTION III - KILLED OR INJURED (Use Section VIII if additional space is needed.)

A

46.

SECTION I - FEDERAL VEHICLE DATA

4b. WORK TELEPHONE NUMBER

10. SEAT BELTS USED

14b. WORK TELEPHONE NUMBER

15b. HOME TELEPHONE NUMBER

17. ESTIMATED REPAIR COST

22c. TELEPHONE NUMBER

24b. TELEPHONE NUMBER

40. MARK "X" IN TWO APPROPRIATE BOXES 41. IN WHICH VEHICLE

30. MARK "X" IN TWO APPROPRIATE BOXES 31. IN WHICH VEHICLE

b. DIRECTION OF PEDESTRIAN (SW corner to NE corner, etc.)

Pedes-trian

( )

( )

( )

NO

CO-OWNED

LEASED ( ) RENTAL

PRIVATELY OWNED

DRIVER

HELPER

KILLED

INJURED

PASSENGER

PEDESTRIAN

FED

OTHER (2)

FED

OTHER (2)

DRIVER

HELPER

KILLED

INJURED

PASSENGER

PEDESTRIAN

$

11. DESCRIBE VEHICLE DAMAGE

1. DRIVER'S NAME (Last, first, middle)

4a. DEPARTMENT/FEDERAL AGENCY PERMANENT OFFICE ADDRESS

12. DRIVER'S NAME (Last, first, middle)

14a. DRIVER'S WORK ADDRESS

15a. DRIVER'S HOME ADDRESS

16. DESCRIBE VEHICLE DAMAGE

20. MODEL OF VEHICLE

2. DRIVER'S LICENSE NO./STATE/LIMITATIONS

3. DATE OF ACCIDENT

5. TAG OR IDENTIFICATION NUMBER 8. MAKE 9. MODEL

13. DRIVER'S LICENSE NUMBER/STATE/LIMITATIONS

21. TAG NUMBER AND STATE 18. YEAR OF VEHICLE 19. MAKE OF VEHICLE

7. YEAR OF VEHICLE

$

25. OWNER'S ADDRESS(ES)

22b. POLICY NUMBER 22a. DRIVER'S INSURANCE COMPANY NAME AND ADDRESS

26. NAME (Last, first, middle)

29. ADDRESS

27. SEX 28. DATE OF BIRTH

34. TRANSPORTED BY

32. LOCATION IN VEHICLE 33. FIRST AID GIVEN BY

24a. OWNER'S NAME(S) (Last, first, middle)

35. TRANSPORTED TO

37. SEX 38. DATE OF BIRTH36. NAME (Last, first, middle)

39. ADDRESS

42. LOCATION IN VEHICLE 43. FIRST AID GIVEN BY

44. TRANSPORTED BY 45. TRANSPORTED TO

a. NAME OF STREET OR HIGHWAY

FROM TO

c.

YES

NSN 7540-00-634-4041 Previous edition not usable

STANDARD FORM 91 PAGE 1 (REV. 2-93)Prescribed by GSA-FPMR 101-38.6USAPPC V1.00

91-109

b.

c.

d.

e.

Use one of these outlines to sketch thescene. Write in street or highway names ornumbers.

a.

Example:

Use solid line to show pathbefore accidentand broken line afterthe accident

Show pedestrian by

Show railroad by

Place arrow in this circle to indicate NORTH

Number Federal vehicle as 1, othervehicle as 2, additional vehicle as 3 andshow direction of travel with arrow.

SECTION VII - POLICE INFORMATION

51.

c. L. FRONT

e. R. REAR

d. REAR

52.

POINT OF IMPACT (Check one foreach vehicle)

49. TIME OF ACCIDENT

SECTION V - WITNESS/PASSENGER (Witness must fill out SF 94, Statement of Witness) (Continue in Section VIII.) 54. WORK TELEPHONE NUMBER

SECTION VI - PROPERTY DAMAGE (Use Section VIII if additional space is needed.)

SECTION IV - ACCIDENT TIME AND LOCATION (Use Section VIII if additional space is needed.)

50. INDICATE ON THIS DIAGRAM HOW THE ACCIDENT HAPPENED

55. HOME TELEPHONE NUMBER

A

B

59. WORK TELEPHONE NUMBER 60. HOME TELEPHONE NUMBER

63b. OFFICE TELEPHONE NUMBER 63c. HOME TELEPHONE NUMBER

67. ESTIMATED COST

68c. TELEPHONE NUMBER

AREA FED

64b. TELEPHONE NUMBER

PLACE OF ACCIDENT (Street address, city, state, ZIP Code; Nearest landmark; Distance nearest intersection: Kind of locality(industrial, business, residential, open country, etc.); Road description).

2

g. R. SIDE

a. FRONT

b. R. FRONT

f. L. REAR

h. L. SIDE

1 2

2

2

( ) ( )

( ) ( )

( ) ( )

( )

( )

DESCRIBE WHAT HAPPENED (Refer to vehicles "Fed", "2", "3", etc. Please include information on posted speed limit, approximate speed of the vehicles, roadconditions, weather conditions, driver visibility, condition of accident vehicles, traffic controls (warning light, stop signal, etc.) condition of light (daylight, dusk,night, dawn, artificial light, etc.), and driver actions (making U-turn, passing, stopped in traffic, etc.).

47. DATE OF ACCIDENT 48.

70b. VIOLATION(S)

63d. BUSINESS ADDRESS

64a. NAME OF INSURANCE COMPANY

66. LOCATION OF DAMAGED ITEM

68b. BADGE NUMBER

63a. NAME OF OWNER

56. BUSINESS ADDRESS

58. NAME (Last, first, middle)

61. BUSINESS ADDRESS

53. NAME (Last, first, middle)

57. HOME ADDRESS

62. HOME ADDRESS

63e. HOME ADDRESS

68a. NAME OF POLICE OFFICER

69. PRECINCT OR HEADQUARTERS 70a. PERSON CHARGED WITH ACCIDENT

65. ITEM DAMAGED

64c. POLICY NUMBER

$

STANDARD FORM 91 PAGE 2 (REV. 2-93)USAPPC V1.00

AMPM

SECTION VIII - EXTRA DETAILS

In compliance with the Privacy Act of 1974, solicitation of the information requested on this form is authorized by Title 40 U.S.C. Section491. Disclosure of the information by a Federal employee is mandatory as the first step in the Government's investigation of a motorvehicle accident. The principal purposes for using this information is to provide necessary data for legal counsel in legal actions resultingfrom the accident and to provide accident information/statistics in analyzing accident causes and developing methods of reducing accidents.Routine use of information may be by Federal, State or local governments, or agencies, when relevant to civil, criminal, or regulatory investigations or prosecutions. An employee of a Federal agency who fails to report accurately a motor vehicle accident involving a Federal vehicle or who refuses to cooperate in the investigation of an accident may be subject to administrative sanctions.

a.m.p.m.

a.m.p.m.

DID THE OPERATOR, WHILE ENROUTE, ENGAGE IN ANY ACTIVITY OTHERTHAN THAT FOR WHICH THE TRIP WAS AUTHORIZED.

81.

SPACE FOR DETAILED ANSWERS. INDICATE SECTION AND ITEM NUMBER FOR EACH ANSWER. IF MORE SPACE IS NEEDED, CONTINUE ITEMS ON PLAIN BOND PAPER.

SECTION IX - FEDERAL DRIVER CERTIFICATION

71b. DRIVER'S SIGNATURE AND DATE

I certify that the information on this form (Sections I thru VIII) is correct to the best of my knowledge and belief.

SECTION X - DETAILS OF TRIP DURING WHICH ACCIDENT OCCURRED

TIME (Circle one)

a. DID THIS ACCIDENT OCCUR WITHIN THE EMPLOYEE'S SCOPE OF DUTY

82b. SUPERVISOR'S SIGNATURE AND DATE 82c. TELEPHONE NUMBER

COMPLETED BYDRIVER'SSUPERVISOR

75. TRIP BEGAN 76. ACCIDENTOCCURRED

TIME (Circle one)

IN WRITING (Explain) ORALLY

YES

YES (Explain) NO

YES (Explain) NO NO (Explain)

( )

YES

NO

80.

b. COMMENTS

82a. NAME AND TITLE OF SUPERVISOR

71a. NAME AND TITLE OF DRIVER

72. ORIGIN

74. EXACT PURPOSE OF TRIP

77. AUTHORITY FOR THE TRIP WAS GIVEN TO THE OPERATOR

79. WAS THE TRIP MADE WITHIN ESTABLISHED WORKING HOURS

73. DESTINATION

78. WAS THERE ANY DEVIATION FROM DIRECT ROUTE

DATE DATE

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84. PERSONS INTERVIEWEDDATE

88. ACCIDENT REVIEWING OFFICIAL

SECTION XI - ACCIDENT INVESTIGATION DATA

c.

d.

e. OFFICE TELEPHONE NUMBER ( ) ( )

e. OFFICE TELEPHONE NUMBER

NAME

SECTION XII - ATTACHMENTS

SECTION XIII - COMMENTS/APPROVALS

a. SIGNATURE AND DATE

87. ACCIDENT INVESTIGATORa. SIGNATURE AND DATE

NAME DATE

YES NO (If "Yes", explain below.)

( ) ( )

a.

b.

85. ADDITIONAL COMMENTS (Indicate section and item number for each comment.)

83. DID THE INVESTIGATION DISCLOSE CONFLICTING INFORMATION.

LIST ALL ATTACHMENTS TO THIS REPORT

86. REVIEWING OFFICIAL'S COMMENTS

b. NAME (First, middle, last)

c. TITLE

d. OFFICE

b. NAME (First, middle, last)

c. TITLE

d. OFFICE

STANDARD FORM 91 PAGE 4 (REV. 2-93)USAPPC V1.00