Opening: This is (name of adjuster) taking a recorded (personal or telephone) interview with (name of person being interviewed) on (date of interview) at (location where interview is being taken) concerning an incident which took place on (date of incident) at (location of incident).
 
 

OPENING STATEMENT
(All Statements)

BEGIN WITH:

This is _________________conducting a recorded interview
 (your name)
with______________________at______________________
 (person’s name)          (location)

Today’s date is __________  The time is __________________

We are going to discuss details of an accident which occurred on________________ and in which ______________________
            (date of accident)          (interviewee’s name)
was _______________________________________________
    (How involved- driver, witness,  passenger, pedestrian, etc.)

Then continue with identification
 
 
 

1. DO YOU UNDERSTAND THAT THIS INTERVIEW IS BEING RECORDED?

2. DO YOU AGREE THAT IT IS ALL RIGHT TO RECORD THE INTERVIEW?

3. WOULD YOU STATE YOUR FULL NAME, AND SPELL YOUR LAST NAME,  PLEASE?

4. WHAT IS YOUR DATE OF BIRTH?

5. WHAT IS YOUR SOCIAL SECURITY NUMBER, PLEASE?

6. WHAT IS YOUR ADDRESS (CITY, STATE & ZIP)?

7. WHAT IS YOUR TELEPHONE NUMBER?

8. ARE YOU SINGLE OR MARRIED?

9. IF MARRIED, WHAT IS YOUR (WIFE - HUSBAND'S) NAME?

10. WHERE ARE YOU EMPLOYED?

11. HOW LONG HAVE YOU WORKED THERE?

12. WHAT IS THE NATURE OF YOUR JOB?

13. ARE YOU A LICENSED DRIVER?  (IF UNDER 18 YEARS OF AGE)
  WHO SIGNED THEIR DRIVERS LICENSE?

14. ARE THERE ANY RESTRICTIONS ON YOUR LICENSE?  (IF YES, WHAT?)

15. ARE YOU ON ANY TYPE OF MEDICATION?  (IF YES, WHAT?)

16. WERE YOU WEARING GLASSES AT THE TIE OF THE ACCIDENT?

17. WHAT WAS THE DATE AND TIME OF THE ACCIDENT, WITH WHICH WE ARE  CONCERNED HERE?

18. WHERE DID IT HAPPEN?  (GET PRECISE LOCATION)

19. WHAT WERE THE WEATHER CONDITIONS?  (RAINING - WERE WINDSHIELD  WIPERS ON?   NIGHT OR DARK - WERE HEADLIGHTS ON?)

20. WHAT KIND OF CAR WERE YOU DRIVING AT THE TIME OF ACCIDENT?

21. IN WHOSE NAME IS THIS CAR TITLED?  (IF OWNER AND DRIVER ARE    DIFFERENT WHAT WAS THE PURPOSE OF THE TRIP?)

22. WHAT WAS THE MAKE AND STYLE OF OTHER CAR?

23. WHO IS THE OWNER?  (NAME, AGE AND ADDRESS)

24. WHO WAS DRIVING?  (NAME, AGE AND ADDRESS)

25. DESCRIBE TYPE OF STREET OR ROADWAY  (STRAIGHT, CURVED, GRADE          TWO LANE, FOUR LANE, CONCRETE, BRICK, ASPHALT, DIRT OR GRAVEL?

26. ON WHAT STREET OR ROAD WERE YOU TRAVELING?

27. IN WHICH DIRECTION?

28. ON WHAT PORTION OF THE HIGHWAY WERE YOU DRIVING?  (WHAT LAND,  ETC.)

29. ON WHAT STREET OR ROAD WAS THE OTHER CAR?

30. IN WHAT DIRECTION WAS IT TRAVELING?

31. IN WHAT LANE WAS THE OTHER CAR?

32. HOW FAR FROM THE OTHER CAR WERE YOU WHEN YOU FIRST OBSERVED  IT?

33. HOW FAST WAS IT TRAVELING AT THAT TIME?

34. HOW FAST WAS IT TRAVELING AT TIME OF IMPACT?

35. WHAT WAS YOUR SPEED WHEN YOU FIRST SAW THE OTHER CAR?

36. WHAT WAS YOUR SPEED AT THE TIME OF IMPACT?

37. WERE THERE ANY TRAFFIC CONTROLS WHERE THIS ACCIDENT TOOK  PLACE?    IF SO EXPLAIN.    (IF A TRAFFIC LIGHT IS CONCERNED - WHAT
 WAS THE EXACT POSITION OF THE AUTO'S AT THE TIME THE LIGHT    CHANGED?

38. WHAT EFFORT DID YOU MAKE TO AVOID THE ACCIDENT?

39. WHAT EFFORT DID THE OTHER DRIVER MAKE TO AVOID THE  ACCIDENT?

40. WAS THERE ANY CONDITION OR OBJECT WHICH OBSTRUCTED YOUR  VIEW OF THE OTHER CAR BEFORE THE IMPACT?  (IF SO DESCRIBE)

41. WHAT WAS THE POSITION OF THE TWO CARS JUST PRIOR TO IMPACT?

42. WHAT WAS THEIR RESPECTIVE POSITIONS AT THE TIME OF IMPACT?
 (DESCRIBE IMPACT AND POINTS OF CONTACT)

43. WHAT WAS THE POSITION OF EACH CAR AFTER THE COLLISION?

44. WAS ANYTHING ELSE STRUCK BY EITHER VEHICLE AFTER THE INITIAL  IMPACT?

45. WERE THERE ANY VISIBLE SKID MARKS ON THE STREET OR ROAD   SURFACE?   (IF SO WHO MEASURED THEM)

46. WAS YOUR CAR EQUIPPED WITH SEAT BELTS?

47. IF SO WAS YOUR SEAT BELT FASTENED?

48. WAS THE OTHER CAR EQUIPPED WITH SEAT BELTS?

49. IF SO DID THE OTHER DRIVER HAVE THERE BELT FASTENED?

50. DESCRIBE THE DAMAGE TO YOUR CAR

51. DESCRIBE THE DAMAGE TO THE OTHER CAR

52. WHAT IS THE POSTED SPEED LIMIT AT THE SCENE OF THE ACCIDENT?

53. HAVE YOU TRAVELED THIS AREA BEFORE?   (ARE YOU FAMILIAR WITH  THIS AREA?

54. HAD YOU BEEN DRINKING?   (IF YES WHERE?)

55.  WAS THERE ANY INDICATION THAT THE OTHER DRIVER HAD BEEN   DRINKING?   (IF SO WHAT?)

56. WHO INVESTIGATED THE ACCIDENT?  (CITY POLICE, SHERIFF, OR STATE  PATROL)
57. DID EITHER DRIVER RECEIVE A CITATION?

58. WHAT WAS THE OUTCOME?

59. DID YOU OVERHEAR ANY CONVERSATION BETWEEN THE POLICE OFFICER  AND THE OTHER DRIVER?

60. IF YES, WHAT WAS SAID?

61. DID YOU HAVE ANY CONVERSATION WITH THE OTHER DRIVER OR    PASSENGERS IN THE OTHER CAR OR ANY WITNESSES?

62. WHAT WAS SAID IN EACH CONVERSATION?

63. WERE THERE ANY WITNESSES TO THIS ACCIDENT?

64. IF SO, DID YOU GET THE NAMES, ADDRESSES AND AGES OF EACH?

65. DID YOU HAVE ANY PASSENGERS?

66. IF SO, DID YOU GET THE NAMES, ADDRESSES AND AGES OF PASSENGERS?

67. WERE THERE ANY PASSENGERS IN THE OTHER CAR?  (NAME, ADDRESSES  AND AGE?)

68. WERE THERE ANY INJURIES SUSTAINED IN THIS ACCIDENT?

69. IF SO, WHO WAS INJURED?   ( NATURE OF INJURIES)

70. YOU HAVE SUGGESTED THAT YOU SUSTAINED (DESCRIBE INJURES) IN  THE COLLISION.  DID YOU REQUIRE ANY TREATMENT IN A HOSPITAL?

71. IN WHAT HOSPITAL WERE YOU TREATED?

72. HOW LONG WERE YOU CONFINED?

73. WHAT DOCTOR IS TREATING YOU FOR YOUR INJURIES?

74. HAVE YOU RECOVERED FROM THE INJURIES WHICH YOU SUSTAINED?

75. DID YOU HAVE ANY OTHER EXPENSE OR LOSS AS A RESULT OF YOUR  INJURIES?

76. IF YES, GIVE THE NATURE AND AMOUNT

77. WERE YOU REQUIRED TO LOSE TIME FROM YOUR EMPLOYMENT?

78. IF SO, FOR WHAT PERIOD OF TIME?

 NOTE: IF MORE THAN ONE PERSON WAS INJURED, THE PRECEDING EIGHT   QUESTIONS (71 TO 78) SHOULD BE ANSWERED FOR EACH

79. HAVE YOU EVER BEEN INVOLVED IN ANY OTHER AUTO ACCIDENT?
 IF SO, WHEN?

80. HAVE YOU EVER BEEN INVOLVED IN ANY WORKMAN'S COMP ACCIDENT?
 IF SO, WHEN?
 
 
 

CLOSING

IS THERE ANYTHING YOU WOULD LIKE TO ADD TO THIS INTERVIEW, CONCERNING THIS INCIDENT, IN WHICH WE HAVE NOT ALREADY COVERED?

HAVE YOU UNDERSTOOD ALL OF THE QUESTIONS ASKED?

IS ALL OF THE INFORMATION THAT YOU HAVE GIVEN TRUE TO THE BEST OF YOUR KNOWLEDGE?

DO YOU UNDERSTAND THAT THIS INTERVIEW HAS BEEN RECORDED?

AND IT IS WITH YOUR PERMISSION THAT WE DID RECORD IT?

THANK YOU

THIS CONCLUDES THIS RECORDING
 
 

Provided by TLC Publication
Janice J. Foote
Ohio Adjuster's Directory