B. Safety System Used
0 None used
1 Shoulder and lap belt
2 Lap belt only
3 Shoulder belt only
4 Child safety seat
5 Helmet
99 Unknown
A. Seating Position
1 Front seat - left side (or motorcycle driver)
2 Front seat - middle
3 Front seat - right side
4 Second seat - left side (or motorcycle passenger)
5 Second seat - middle
6 Second seat - right side
7 Third row - left side (or motorcycle passenger)
8 Third row - middle
Please Indicate the Sequence of Events as they occurred to YOUR Vehicle by writing the corresponding number (1-52, or 97, 99) in up to 4 boxes below.
What happened first? What happened 2
nd
(if applicable)? What happened 3
rd
(if applicable)? What happened 4
th
(if applicable)?
Collision with
1 Motor vehicle in traffic
2 Parked motor vehicle
3 Pedestrian
4 Cyclist
5 Animal- deer
6 Animal- other
7 Moped
8 Work zone maintenance equipment
9 Railway vehicle (train, engine)
10 Other movable object
11 Unknown movable object
20 Curb
21 Tree
22 Utility pole
Was Vehicle Damage
__Yes ___No
above $1000?
City/Town Where Crash Occurred Date of Crash Time of Crash
____ : ____ __ AM __ PM
Section A: Crash Location
# Vehicles
Involved:
Section B: Vehicle You Were Driving
Number of occupants in vehicle (including yourself): _________ Was vehicle damage above $1000? __Yes __No
Full Name of Vehicle Owner (Last, First, Middle) Street Address City/Town State Zip
23 Light pole or other post/support
24 Guardrail
25 Median barrier
26 Ditch
27 Embankment/Sloping shoulder
28 Highway traffic signpost
29 Overhead sign support
30 Fence
31 Mailbox
32 Crash cushion/Impact attenuator
33 Bridge
34 Bridge overhead structure
35 Other fixed object (wall, building, tunnel)
36 Unknown fixed object
Non-Collision
40 Ran off road right
41 Ran off road left
42 Cross median/centerline
43 Overturn/rollover
44 Equipment failure (blown tire, brakes, etc)
45 Fire/explosion
46 Immersion
47 Jackknife
48 Cargo/equipment loss or shift
49 Separation of units
50 Downhill runaway
51 Other non-collision
52 Unknown non-collision
97 Other
99 Unknown
Was your Vehicle Towed From the Scene Due to Damage? __Yes __No
0 None
10 Undercarriage
11 Totaled
97 Other
99 Unknown
8 7 6
2 3 4
1 9 5
Drivers License Number License State Age Sex
__ M __ F
Date of Birth
Insurance Company
Vehicle Registration #
Reg. Type Reg. State Vehicle Year Vehicle Make
Your Full Name (Last, First, Middle) Street Address City/Town State Zip
SECTION A2: Complete this Section if the crash did NOT occur at an
intersection:
Step 1: Please indicate the route, roadway and address where the crash occurred:
The crash occurred on Route #: _______ at Street or Address Number: ________________
on the Street/Roadway known as: ______________________________________________
Step 2: Please provide as much of the following specific location information as possible:
The crash occurred (estimate number of feet) _______________ feet
(indicate direction as N/S/E/W) _______________ of
a) Mile Marker number ___ ___ ___ ___
OR: b) Exit Number ________________
OR: c) Intersecting Street/Roadway __________ ___________________________
Route# Name of Roadway/Street
OR: d) Landmark _______________________________________________________
Please complete Section A1 or A2 below to indicate the location of the crash.
If you need additional space to describe the crash location, please use Section J on the last page of this form.
A B C D E F G H Name of
Medical Facility
Section C: You and Your Passengers
Date of
Birth/Age
Sex
M/F
Driver (See previous page)
Name of Passenger 1 (Last, First, Middle)
Name of Passenger 2 (Last, First, Middle)
Name of Passenger 3 (Last, First, Middle)
Address
City/Town State Zip
Address
City/Town State Zip
Address
City/Town State Zip
9 Third row - right side
10 Sleeper section of cab
11 Enclosed passenger area
12 Unenclosed passenger area
13 Trailing unit
14 Riding on vehicle exterior
97 Other
99 Unknown
Full Name of Vehicle Owner (Last, First, Middle)
Street Address City/Town State Zip
Vehicle Travel
Direction
__N __S
__E __W
Drivers License Number
Insurance Company
Vehicle Registration #
Reg. Type Reg. State Vehicle Year Vehicle Make
License State AgeDate of Birth
Full Name of Vehicle Driver (Last, First, Middle)
Street Address City/Town State Zip
Section E: Non-Motorist(s) Involved in the Crash
Date of Birth/Age
Sex
__M __ F
Full Name of Non-Motorist (Last, First, Middle) Street Address City/Town State Zip
Please provide the full name, address, and DOB or Age for all passengers in your vehicle. Then write the corresponding code in each of the boxes for each occupant of the vehicle
(yourself and all passengers). A list of the possible codes is provided at the bottom of this section.
Indicate the type of non-motorist involved
1 Pedestrian 2 Cyclist 3 Skater 97 Other 99 Unknown
What was the non-motorist doing prior to the crash?
1 Entering or crossing location 6 Working on vehicle
2 Walking, running, or cycling 7 Standing
3 Working 97 Other
4 Pushing vehicle 99 Unknown
5 Approaching or leaving vehicle
Safety Equipment?
0 None used 9 Lighting
6 Helmet 10 Other
7 Protective pads (elbows, knees, etc.) 99 Unknown
8 Reflective clothing If transported, please indicate Hospital/Medical Facility:
Number of occupants in the Vehicle: _____
Hit and Run? __Yes __No
Section D: Other Vehicle(s) Involved in the Crash
Page 3Page 2
__ M __ F
Moped? __Yes __No
Number of injured occupants: _____
Vehicle Damaged Area (circle up to three)
0 None
10 Undercarriage
11 Totaled
97 Other
99 Unknown
195
876
234
SECTION A1: Complete this Section if the crash
occurred at an intersection of two or more streets:
Step 1: Please indicate the route or roadway where you
were travelling when the crash occurred:
____________ __________________________________
Route# Name of Roadway/Street
Step 2: What was the name (or names) of the intersecting
streets?
____________ __________________________________
Route# Name of Roadway/Street
____________ __________________________________
Route# Name of Roadway/Street
OR
Indicate your type of vehicle
1 Passenger car 4 Bus (15 or more passengers) 8 Truck/trailer 12 Tractor/triples 97 Other
2 Light truck (van, mini-van, 5 Bus (7-15 passengers) 9 Truck tractor (bobtail) 13 Unknown heavy truck 99 Unknown
pick-up, sport utility) 6 Single-unit truck (2 axles) 10 Tractor/semi-trailer 14 Motor home/recreational vehicle
3 Motorcycle 7 Single-unit truck (3 or more axles) 11 Tractor/doubles
What Was Your Vehicle Doing Prior to the Crash?
1 Travelling straight ahead 4 Turning left 7 Leaving traffic lane 10 Backing 97 Other
2 Slowing or stopped 5 Changing lanes 8 Making U-turn 11 Parked 99 Unknown
3 Turning right 6 Entering traffic lane 9 Overtaking/passing
Commercial Drivers License Endorsements
H __ Hazardous N __ Tank vehicles P__Passenger
T __ Doubles/Triples X __ Tank and Hazardous transport
C. Air Bag Status
1 Deployed-front
2 Deployed-side
3 Deployed both
front and side
4 Not deployed
5 Not applicable
99 Unknown
D. Air Bag Switch
1 Switch in ON position
2 Switch in OFF position
3 ON-OFF switch not present
4 Unknown if switch is present
99 Unknown
E. Ejected From Vehicle?
0 Not ejected
1 Totally ejected
2 Partially ejected
3 Not applicable
99 Unknown
F. Trapped?
0 Not trapped
1 Freed by mechanical means
2 Freed by non-mechanical means
99 Unknown
G. Injured?
1 Fatal injury
Non-fatal injury:
2 Incapacitating 5 No injury
3 Non-incapacitating 99 Unknown
4 Possible
H. Transported for Medical Care?
1 Not transported 97 Other
2 EMS (emergency service) 99 Unknown
3 Police
Commercial Drivers License Endorsements
H __ Hazardous N __ Tank vehicles P__Passenger
T __ Doubles/Triples X __ Tank and Hazardous transport
Indicate type of vehicle
1 Passenger car 4 Bus (15 or more passengers) 8 Truck/trailer 12 Tractor/triples 97 Other
2 Light truck (van, mini-van, 5 Bus (7-15 passengers) 9 Truck tractor (bobtail) 13 Unknown heavy truck 99 Unknown
pick-up, sport utility) 6 Single-unit truck (2 axles) 10 Tractor/semi-trailer 14 Motor home/recreational vehicle
3 Motorcycle 7 Single-unit truck (3 or more axles) 11 Tractor/doubles
What Was the Vehicle Doing Prior to the Crash?
1 Travelling straight ahead 4 Turning left 7 Leaving traffic lane 10 Backing 97 Other
2 Slowing or stopped 5 Changing lanes 8 Making U-turn 11 Parked 99 Unknown
3 Turning right 6 Entering traffic lane 9 Overtaking/passing
License Class
__ D __ A __B __C
__ M __ Unknown
Vehicle Travel Direction
__N __S __E __W
Vehicle Damaged Area
(circle up to three)
Sex
License Class
__ D __ A __ B __ C
__ M __ Unknown
Where was the non-motorist prior to the crash?
1 Marked crosswalk at intersection 6 Median (but not on shoulder)
2 At intersection but no crosswalk 7 Island
3 Non-intersection crosswalk 8 Shoulder
4 In roadway 9 Sidewalk
5 Not in roadway 10 Shared-use path or trails
99 Unknown
Injured?
1 Fatal injury
Non-fatal injury:
2 Incapacitating 5 No injury
3 Non-incapacitating 99 Unknown
4 Possible
Transported for Medical Care?
1 Not transported 97 Other
2 EMS (emergency service) 99 Unknown
3 Police