Autonomous Vehicles Incident Form

  • Please do not include any sensitive personal information such as your social security number, driver license number, or financial account number on the form.

    Fields with an asterisk (*) are required.

    If you do not have the specific information required, please type unk or unknown in the field.

  • Autonomous Vehicle Information

  • MM slash DD slash YYYY
  • Please provide a description of the incident.
  • Contact Information

    If you would like to provide any additional feedback, please submit your contact information.

  • Name

Notice on Collection of Personal Information

Providing Personal Information Is Voluntary. You do not have to provide the personal information requested. If you do not wish to provide personal information, such as your name, home address, or home telephone number, you may remain anonymous. In that case, however, we may not be able to contact you or conduct further investigation into your complaint.

For more information, visit the Department of Motor Vehicle’s DMV and Your Information page.

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