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2. This report is to be used by any citizen involved in a vehicle accident or incident occurring on municipal property which may or may not have required first-aid or hospital treatment, or resulted in the citizen complaining of discomfort or damage to private property as a result of the incident.
   
4. * indicates required field
6. Name:*
8. Phone Number:*
10. Email Address:
12. Address
14. City
15. State
16. Zip Code
18. Date of Incident (mm/dd/yyyy):*
20. Time of incident:*
22. Please further identify time of incident:*

    1. AM
    2. PM
24. Exact Location of Incident:*
26. Describe Accident/Injury:*
28. List All Witnesses: (Please include name, address and phone number, if known.)*
30. Was First-Aid Given?

    1. Yes
    2. No
32. Type of First-Aid Given (if applicable): (Please include name, address and phone number of those who gave first aid)*
34. Please provide the date and time that any first aid treatment was given:
36. Was Medical Emergency Treatment Given?*

    1. Yes
    2. No
38. If medical emergency treatment was given, what paramedics/hospital/doctor provided it? (Please give names, address and phone numbers for all treatment providers.)*
40. Please provide the date and time that any medical emergency treatment was given:*
42. Any Other Comments:
44. Please sign and date below.
46. Signature:*
47. Date:*
49. Please return the completed form by clicking either Submit or Submit and Print below, or by mailing to:
    Village of Lombard
    ATTN: Village Manager's Office
    255 E. Wilson Ave.
    Lombard, IL 60148.
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51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field