Employee Driving Through Fog Form

EMPLOYEE DRIVING THROUGH FOG FORM

Purpose and Instructions

This form documents circumstances, actions, and observations when an employee operates a vehicle in fog or severely reduced visibility while on company business. Complete this form fully and submit it to Human Resources and Fleet Safety within 24 hours of the event. Incomplete or false statements may result in disciplinary action.

Personal Information

Position and Employment

Trip / Incident Details

Date of event:    Time of event:

Company vehicle    Personal vehicle used for business    Rental vehicle

Fog Conditions and Visibility

Visibility estimated at:    Road surface:

Reduced speed    Used low beam headlights    Activated fog lights    Increased following distance    Pulled off roadway and stopped

Hazards, Incidents, and Damage

Collision    Near miss    Property damage    None

Vehicle Condition and Pre-Trip Checks

All items applicable were checked prior to departure:

Tire condition adequate    Brake system functional    Lights operational (headlights, tail, fog)    Windshield wipers and fluid sufficient    Defogger/ventilation functional

Witnesses / On-scene Contacts

Employment History (for HR records)

Employer 1 — Company Name

Employer 2 — Company Name

Education

Professional References

Legal Disclosures and Acknowledgements

At-Will Employment: Employee acknowledges that employment status, if applicable, is at-will and may be terminated by either the employee or employer at any time, with or without cause or notice, except as otherwise provided by written agreement signed by an authorized representative of the company.

Equal Opportunity: The company provides equal employment opportunity to all employees and applicants without regard to protected characteristics. Safety and compliance with company driving policies are required of all employees operating vehicles on company business.

I certify that the foregoing statements are true and complete to the best of my knowledge. I understand that omission of material facts or submitting false information may subject me to disciplinary action up to and including termination. I authorize the company to contact prior employers, references, and insurance providers as needed to verify information relevant to this report and any subsequent investigation.

I certify that the information provided on this form is true and accurate.    I authorize contact with prior employers and relevant parties for purposes of investigation.

Supervisor Review (for HR use)

Final Statement and Warning

WARNING: Knowingly providing false or misleading information on this form is a serious matter and may result in disciplinary action, up to and including termination. This form will be retained in the employee's personnel and fleet safety records and may be used in determining fitness for continued driving privileges on company business.

Sign Now