BUS PASSING COMPLAINTS

Date of Violation:
Time of Violation  (HH:MM):

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 Vehicle Description:

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

Incident Details

Was school bus stopped?  Select Yes No

How far away did you activate amber lights? ft.

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?  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 up at any time, while approaching the bus or after passing the bus?  Select Yes No

Vehicle was estimated to be traveling at approximately? m.p.h.

Speed Limit of Road m.p.h.

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:  YesNo

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:

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