AFP Crash Report

About this form

Use this form to provide details about a crash in the ACT. The form will take a few seconds to fully load to
your browser and on average will take you 15 minutes to complete.
Please ensure you have your drivers licence and vehicle registration details with you and, where possible,
similar details about the other drivers and vehicles involved in the crash. If you are filling out this form on
behalf of another party then questions using the word "you" refer to that person. Once this form is
submitted, print or save a copy for your records so you have it available for insurance or other purposes.
This form is only for crashes occurring in the ACT. If the crash you were involved in occurred outside of the
ACT you do not need to complete this form.
It is an offence to submit this form knowing you have supplied false or misleading information. If you require
assistance please call the Australian Federal Police on 131444.
All fields are optional unless stated otherwise.
The ACT Government is committed to improving the accessibility of web content. To provide feedback or
request an accessible version of a document please phone 13 22 81.

Reporting requirements
Did any person involved in the crash get transported from the
scene by ambulance to receive medical treatment? (Mandatory)

Yes

Did the police complete an official report regarding this crash? (Mandatory)

No

Yes

i
No

Unsure

Crash site details

Day (Mandatory)

Date (Mandatory)

Thursday

24/09/2015

Time (Mandatory)
1.00

dd/mm/yyyy

am/pm (Mandatory)
hh.mm

pm

e.g. 07.38pm

Location of crash (Mandatory)

Road (incl. kerb-side parking)
Street
Mort Street
To view a map of the crash location, please click on the link below OR copy the link below (without the
quotes) and paste it into your web browser
"http://maps.google.com/staticmap?
markers=-35.27673219605964,149.13089756440968&zoom=16&size=900x900&key=ABQIAAAA1MKP9ZoT_9SNUZQJ1xDYphSXz
mP4kd58BI6e5w3SkNXrSfNIIBT1WOiQOHD84NaBahqoTyYz5rMk3Q&sensor=false"

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Description of location (e.g. adjacent to house number, landmarks, shops) (Mandatory)

It was opposite of building 14

Weather conditions (Mandatory)

Fine
Light conditions (Mandatory)
Daylight
Traffic control (Mandatory)
Uncontrolled
Crash site (Mandatory)
Normal road
Road conditions (Mandatory)
Good dry surface
Road gradient
Unknown
Road style
Straight
Road division
Unknown
Pedestrian Information
Were you a pedestrian involved in the crash? (Mandatory)

Yes

No

Were any pedestrians involved in the crash? (Mandatory)

Yes

No

Vehicle information
Vehicle 1 is the vehicle you were driving. If you were a pedestrian in the crash then vehicle 1 is
the vehicle that hit you or came closest to hitting you. If there were other vehicles in the crash
please provide details about them by clicking the add vehicle button at the bottom of this step.
Number of vehicles
2

1
Type of vehicle (Mandatory)
Taxi or hired car

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Vehicle Details
State of current vehicle registration (Mandatory)
ACT
Vehicle registration number (Mandatory)
412
Registration expiry date
dd/mm/yyyy
Make
Ford

e.g. Ford

Model
Falcon

e.g. Falcon

Colour

Year of manufacture

White

2007

e.g. 2001

Damage to the vehicle

Major damage
Damage details
Broke right front bumper along side the wheel.

Did the vehicle get towed away?

No
Was the driver the owner of this vehicle?
No
Owner's name
Muhammad Amir
Was another vehicle attached to the vehicle
e.g. Caravan, trailer, boat

No

Drivers Licence Details

Current drivers licence state (Mandatory)
NSW
Licence number
21978968
Licence expiry date
01/07/2018

dd/mm/yyyy

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If the drivers licence shows more than one class, please enter the class that applies to the vehicle involved
in this crash.
Licence vehicle class (for vehicle involved in crash)
(Mandatory)
Car (motor vehicle up to 4.5 tonnes)
Licence class type (for vehicle involved in crash)
(Mandatory)
Full
Does the driver have another class on their licence?
No

Driver Details
Gender (Mandatory)
Male
Date of birth (Mandatory)
01/07/1993

dd/mm/yyyy

Full name
Arif Uddin
Address
1/31, Marshall St, Farrer
Phone number
0470248136
Did the driver sustain injuries that required
any attention at the crash site? (Mandatory)
No
Was driver wearing a seatbelt
Belt worn

Passenger Details
Were there any passengers in/on this vehicle (Mandatory)
No

2
Type of vehicle (Mandatory)
Unknown

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Did the driver of this vehicle fail to stop to provide their details to the other
parties involved? (Mandatory)
No

Vehicle Details
State of current vehicle registration
ACT
Vehicle registration number
YHH77T
Registration expiry date
dd/mm/yyyy
Make
Volkswagen

e.g. Ford

Model
e.g. Falcon
Colour

Year of manufacture
e.g. 2001

Black
Damage to the vehicle
Minor damage
Damage details
Side door scratched on left side.

Did the vehicle get towed away?

No
Was the driver the owner of this vehicle?
Yes
Was another vehicle attached to the vehicle
e.g. Caravan, trailer, boat

No

Drivers Licence Details

Current drivers licence state
ACT
Licence number
2090167
Licence expiry date
31/08/2017

dd/mm/yyyy

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If the drivers licence shows more than one class, please enter the class that applies to the vehicle involved
in this crash.

Licence vehicle class (for vehicle involved in crash)

Car (motor vehicle up to 4.5 tonnes)
Licence class type (for vehicle involved in crash)
Full
Does the driver have another class on their licence?
No

Driver Details
Gender
Female
Date of birth
31/08/1977

dd/mm/yyyy

Full name
Kim Mallett
Address
18 Swinney St, Casey, ACT 2913
Phone number
0420946836
Did the driver sustain injuries that required
any attention at the crash site?
No
Was driver wearing a seatbelt
Unknown

Passenger Details
Were there any passengers in/on this vehicle
No

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Crash Conditions
Please select one option from the 22 below that best describes the collision (Mandatory)
Vehicle to vehicle collision

Single vehicle collision

on roadway

Single vehicle collision

off roadway

Right turn into oncoming vehicle

Struck pedestrian

Struck pedestrian

Right angle collision

Struck animal

Struck vehicle

Acute angle-same direction

Struck object

Struck animal

Acute angle-opposite direction

Overturned

Struck object

Head on collision

Fall from moving vehicle

Overturned

Rear end collision

Other collision

No object struck

Collision with parked vehicle

Other collision

Collision with one vehicle reversing

Other collision

Movement of vehicle (Mandatory)

1

U-turn
Movement of vehicle (Mandatory)

Straight ahead

Please use the map at step 2 to aid in determining each vehicle's direction.
North is at the top of the map.
Direction of vehicle (Mandatory)
1

South West
Direction of vehicle (Mandatory)

South
Vehicle position (Mandatory)

Not related to intersection

Vehicle position (Mandatory)

Not related to intersection

Vehicle lane (Mandatory)

1st (kerb or left) lane

Vehicle lane (Mandatory)

Shoulder
Vehicle action

Proceeding normally
Vehicle action

Out of control
Vehicle headlights

Not applicable
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Vehicle headlights
2

Not applicable
Visibility restrictions (Mandatory)

Not obstructed
Visibility restrictions (Mandatory)

Unknown

Was a fixed object struck by any vehicle in the crash?

Yes

No

Was any other property damaged?

Yes

No

Describe how the crash occurred (5 to 10 lines) (Mandatory)

On Mort street i was going to do U turn for taxi rank with having right shoulder check and there was no
car or traffic but suddenly the lady driver came up with speeding and did not stop at all which ended up
with crashing my vehicle with my front right bumper of the car with her left side door in the middle.

Witness information
Did anybody witness the crash? (Mandatory)

Yes

No

Declaration
Full name (Mandatory)
Arif Uddin
Address (Mandatory)
1/31, Marshall St, Farrer
I declare that I was one of the drivers/pedestrians or a representative of one of the drivers/pedestrians
involved in the crash detailed in this report, and I declare that the information that I have supplied in
this report is true and correct and complete to the best of my ability. (Mandatory)
Submit
Send me a copy of this completed form via email?
Please enter your email address below and then confirm it is correct by entering it again. The 2 addresses
must match in order for us to email you a copy of this form.
Email address (Mandatory)
arif.uddin@live.com.au
Confirm Email address (Mandatory)
arif.uddin@live.com.au

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Submission Acknowledgement
Your form has been successfully submitted. Please keep a copy of this acknowledgement for your records.
In most cases the AFP will NOT need to contact you regarding your report. Please retain a copy for your
records and if necessary, provide the form submission ID to your insurer.
Please note, it is not possible to amend the information in the crash report once it has been submitted. If
you require a correction for insurance purposes, you could contact your insurance company directly or
alternatively, submit a new crash report and make reference to your original report in the Comments.
If your insurance company requires a copy of the other partys crash report, you can request their report
from the ACT Police here: http://www.police.act.gov.au/contact/request-for-act-policing-reports.aspx.
Date and time.24 Sep 2015 16:26:26
Form submission ID. 99102120150924164555
To save or print a copy of the completed form and acknowledgement go to the "File" menu and select
"Save as" or "Print".

Australian Federal Police

P.O. Box 401
Canberra ACT 2601
Telephone: 62567777

Personal information contained in this form is collected by the Australian Federal

Police for the purposes of accident investigation, insurance, and on behalf of
owners of property affected by vehicle accidents. In addition, in accordance with
the Commonwealth Privacy Act 1988, the Australian Federal Police may disclose
crash information to the ACT Government for the administration and
enforcement of the road transport legislation, road safety analysis and related
health and educational purposes.

Form ID: 1021

Version:
Date:

13
24 Sep 2015

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