Date of Violation:  Select Date of incident
Time of Violation  (HH:MM):   
Location (cross street/address)
Vehicle Description
License Plate Number:   State of Plate:  
Type (Truck, Van, etc.):   Make (Chev, Ford, etc.):  
Add'l Description:  
Was school bus stopped? 
How far away did you activate your flashing red lights? ft.
How far away was passing vehicle when stop-arm was extended? ft.
Do you think the vehicle had enough time to stop 20 ft. from the bus? 
Did the driver move his or her head to show in any way they saw the bus? 
Did the vehicle slow up at any time, while approaching the bus or after passing the bus? 
Vehicle was estimated to be traveling at approximately? m.p.h.
Speed Limit of Road m.p.h.
Driver Description
Sex: Approximate Age: Color of hair: Length of hair:
Color & type of clothing worn:
Other passengers in vehicle?
Direction of Travel: Bus        Passing Vehicle  
Road conditions (Dry, wet, icy, snowing, etc):
Weather conditions (Sunny, raining, foggy, snowing dark, etc.):
Traffic conditions: Roadway layout (Straight, level, curve, over hill, etc.):
Describe Incident:
Is Video Available:  
I checked my flashing red lights & Stop-Arm that day at       and all were working properly.
The foregoing, which was voluntarily given, is true and correct to the best of my knowledge and recollection.
Bus Driver Name:   Bus Driver Signature:  
Company or School District:  
Bus Company Telephone Number:   Driver's Telephone Number:  
Email Address: