Date of Birth
年 月 日
License Plate Number
Make and Model of Vehicle
縣(市) 區(鄉、鎮、市) 村(里) 鄰 路(街) 段 巷 弄 號之 樓
When and where did it happen?
答： 年 月 日 時 分 ； 地點：
Which direction were you going? Which lane were you in?
How did it happen?
Did you see the other car before the accident happened?
How far were you from the other car?
What was your reaction ?
Where was your vehicle hit?
How badly was it damaged?
How fast were you going?
Did you drink any alcohol before driving?
How many drinks did you have?
What was your breathalyzer test result?
答：□無No □有Yes（飲酒 杯(瓶)；經測定 毫克/公升 。）
Were you using your cell phone while driving?
Did you bring your license and registration with you?
答：□未帶行照 □有帶行照；□未帶駕照 □有帶駕照（駕照種類為： ）
How many people were in your car? Was anyone injured?
What kind of injuries were there?
What things were you carrying in your car?
How much did they weigh?
What did you do after the accident?
Who reported it to the police at that time? How?
Did you remove your vehicle after the accident?
Did you mark your vehicle before you removed it?
How was the weather and visibility?
Were there any obstacles in the roadway?
What color was the traffic light?
Were you able to see the signs and road markings clearly?
十四、問：你是否意識清醒願意接受談話？ 答：□ 是Yes □ 否No
Are you in good condition and willing to be questioned?
Do you have any comments?
Do you want to file charges?
This traffic accident will be analyzed by our precinct within three months. You will be ticketed if the analysis shows that you have violated a traffic law. (Those who have been involved in accidents causing any injury or death will be ticketed within three months after the date of authentication, if it was applied for). Do you have any comments?