BUS PASSING COMPLAINTS

Date of Violation:
Time of Violation  (HH:MM):	A.M.   P.M.

City/Village/Township

Location (cross street/address)

Vehicle Description
License Plate Number:	State of Plate:
Type (Truck, Van, etc.):	Make (Chev, Ford, etc.):
Color:
Additional Description:

Was school bus stopped?  Select Yes No

How far away did you activate amber lights? Give your answer in feet.

How far away did you activate your flashing red lights? Give your answer in feet.

How far away was passing vehicle when stop-arm was extended? Give your answer in feet.

Do you think the vehicle had enough time to stop 20 feet from the bus?  Select Yes No

Did the driver move his or her head to show in any way they saw the bus?  Select Yes No

Did the vehicle slow down at any time, while approaching the bus or after passing the bus?  Select Yes No

How fast, approximately, do you estimate the vehicle was moving? Give your answer in miles per hour.

What was the speed limit of the road where the incident happened? Give your answer in miles per hour.

Driver Description
Sex: Select Male Female Unknown	Approximate Age:	Color of hair:	Length of hair:
Color & type of clothing worn:
Were there other passengers in the vehicle?

Direction of Travel:
Bus:	Passing Vehicle:
Road conditions (Dry, wet, icy, snowing, etc):
Weather conditions (Sunny, raining, foggy, snowing dark, etc.):
Traffic conditions: Select Light Medium Heavy
Roadway layout (Straight, level, curve, over hill, etc.):
Describe Incident:

Is Video Available:   Yes No

Did you check your flashing red lights and your Stop-Arm on the day of the incident and confirm they were all working properly? If so, at what time?

A.M.   P.M.

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: