Motor Vehicle Crash Report - Highway Safety...Motor vehicle traffic accidents have a number of...

Utah Department of Public Safety

Motor Vehicle Crash Report

Data Dictionary Updated May, 2020

Table of Contents

Characteristics of a Motor Vehicle Crash ............................................. 3

Crash Record Fields............................................................................. 5

DI 9 State of Utah Investigating Officer’s Report of Traffic Crash and

Overlay ................................................................................................ 38

Coded Values....................................................................................... 9

Characteristics of a Motor

Vehicle Crash

Characteristics of Motor Vehicle Traffic Accidents

(ANSI D16.1-2007 Manual on Classification of Motor Vehicle Traffic Accidents)

Motor vehicle traffic accidents have a number of characteristics which are used to distinguish between motor vehicle traffic accidents and other events such as non-accidents, aircraft or railway accidents and other motor vehicles, cataclysms and non-traffic accidents. The questions below address all of the distinguishing characteristics of motor vehicle traffic accidents. If the answer to each of the questions below is “yes", the incident is a motor vehicle accident.

1) Did the incident include one or more occurrences of injury or damage?Injury: An injury is bodily harm to a person not including effects of diseases such as stroke, heart attack,

diabetic coma, epileptic seizure, etc

Damage: Damage is harm to property that reduces the monetary value of that property, including harm to wild animals, or birds, which have monetary value. Damage does not include mechanical failure during normal operation, such as tire blowout, broken fan belt, or a broken axle

2) Was there at least one occurrence of injury or damage which was not a direct result of a cataclysm?Cataclysm: A cataclysm is an avalanche, cloudburst, downburst, cyclone, earthquake, flood, hurricane,

landslide/mudslide, lightning, tidal wave, tornado, torrential rain, or volcanic eruption. Does not include natural events such as rain, snow, fog, hail, ice, smog, etc

3) Did the incident involve one or more motor vehicles?Motor vehicle: A motor vehicle is any motorized (mechanically or electrically powered) road vehicle not

operated on rails

4) Of the motor vehicles involved, was at least one in transport?In transport: The term “in transport" denotes the state or condition of a transport vehicle which is in motion

or within the portion of a transport way ordinarily used by similar transport vehicles. When applied to motor vehicles, “in transport" means on a roadway or in motion within or outside the trafficway.

5) Was the incident an unstabilized situation?Unstabilized situation: An unstabilized situation is a set of events not under human control. It originates

when control is lost and terminates when control is regained or, in the absence of persons who are able to regain control, when all persons and property are at rest. Does not include events which are a result of deliberate intent or legal intervention.

6) Did the unstabilized situation originate on a trafficway or did injury or damage occur on a trafficway?Trafficway: A trafficway is any land way open to the public as a matter of right or custom for moving

persons or property from one place to another. A trafficway does not include parking spaces or aisles, or any land way closed to the public.

7) If the incident involved a railway train in transport, did a motor vehicle in transport become involved priorto any injury or damage involving the train?

8) Is it true that neither an aircraft in transport nor a watercraft in transport was involved in the incident?

Crash Record Fields

Crash-level Fields

PS Case NumberCrash Date and TimeCountyCityCrash LocationCase NumberReportable CrashMile PointRoad NameIntersecting Road/PointEMS Time CalledEMS Time ArrivedLaw Enforcement Date/Time Notified of CrashLaw Enforcement Date/Time Arrived at SceneLaw Enforcement Date Investigation CompletedNarrativeNo DiagramRO NameRO BadgeRO DepartmentDate of ReportCrash SeverityWork Zone?Manner Of Collision (two or more motor vehicles in transport)Roadway Contributing CircumstancesWeather ConditionLight ConditionRoadway Surface ConditionRoadway Junction/FeatureRoad JurisdictionPavement Type Location of First Harmful EventFirst Harmful Event

Work Zone = 1Workers Present?Work Zone TypeWork Zone Location

Vehicle-level Fields

Vehicle NumberVINVehicle License Plate StateVehicle License Plate NumberVehicle Registration Expiration Date (MMYY) Vehicle YearVehicle MakeVehicle ModelVehicle ColorMotor Vehicle Body TypeVehicle Trailing Unit(s) Special Function of Motor Vehicle Vehicle Area of Initial ImpactLocation of Damaged Area(s)Vehicle Extent of DamageDirection of Vehicle TravelVehicle Contributing Circumstances Vehicle ManeuverTraffic Control Device Roadway Description Horizontal AlignmentVertical AlignmentPosted SpeedVehicle Posted Advisory SpeedVehicle Estimated Travel SpeedVehicle Estimated Impact SpeedVehicle Speed Estimated By Sequence of EventsMost Harmful EventHit and RunVehicle Estimated DamageTowed StatusCommercial Vehicle

Vehicle Trailing Unit(s) = (1 to 97)Trailer License Plate Number Trailer License Plate StateTrailer License Plate Expiration Date

Commercial Vehicle = 2Motor Carrier NameMotor Carrier AddressUS DOT #CVSA Inspection #GCWR/GVWRHazardous Materials Placard DisplayedHazMat Placard # or Name - Class HazMat ReleasedVehicle Cargo Body Type

Person-level Fields

Person Type NameDOBAgeSexInjury LevelInjury Area Transport By Transported to

Person Type = (1,2) -Vehicle OccupantSeating PositionSafety Equipment Used Any Indication of Improper UseAir Bag DeployedEjectionEjection Path Cause for EjectionExtrication

Person Type = 1 - DriverDriver License StateDriver License NumberDriver License ClassDriver License EndorsementsDriver License StatusCharge Status Driver Condition Speeding-RelatedDriver Contributing Circumstances Driver Distracted ActionVisual Contributing Circumstances Attempted Avoidance ManeuverAlcohol/Drug Use Suspected Alcohol/Drug Test Test Results

Charge Status = 1Charge(s)Citation Number

Driver Distracted Action = (1,2,3)Driver Distracted Source

Person Type = (3,4,5) - Non-MotoristNon-Motorist ActionNon-Motorist Contributing CircumstancesNon-Motorist LocationNon-Motorist Origin/DestinationNon-Motorist Safety EquipmentIncident ResponderNon-Motorist Condition Non-Motorist DistractionAlcohol/Drug Use Suspected Alcohol/Drug Test Test Results Test Results = (1,3)

BAC

Test Results = (2,3)Drug Positive Test Results

Test Results = (1,3)BAC

Test Results = (2,3)Drug Positive Test Results

CodedValues

Crash-level Fields

County Codes

Crash Severity

Manner Of Collision (two or more motor vehicles)

1 Angle2 Front to Rear3 Head On (front-to-front)4 Sideswipe Same Direction5 Sideswipe Opposite Direction6 Parked Vehicle 7 Rear to Side8 Rear to Rear96 Not Applicable/Single Vehicle97 Other*99 Unknown

1 Beaver3 Box Elder5 Cache7 Carbon9 Daggett11 Davis13 Duchesne15 Emery17 Garfield19 Grand21 Iron23 Juab25 Kane27 Millard29 Morgan31 Piute33 Rich35 Salt Lake37 San Juan39 Sanpete41 Sevier43 Summit45 Tooele47 Uintah49 Utah51 Wasatch53 Washington55 Wayne57 Weber

1 No injury/PDO2 Possible injury3 Suspected Minor Injury4 Suspected Serious Injury5 Fatal

Crash-level Fields

City

540 ALPINE650 ALTA760 ALTAMONT870 ALTON980 ALTONAH1090 AMALGA1310 AMERICAN FORK1530 ANETH1750 ANNABELLA1860 ANTIMONY2050 APPLE VALLEY2740 AURORA2960 AVON3180 AXTELL3345 BALLARD3950 BEAR RIVER CITY4060 BEAVER4170 BEAVERDAM4720 BENJAMIN5050 BENSON5270 BERYL5490 BICKNELL5534 BIG WATER6040 BIRDSEYE6370 BLANDING6590 BLUEBELL6700 BLUFF6810 BLUFFDALE6920 BONANZA7360 BOTHWELL7470 BOULDER7690 BOUNTIFUL8020 BRIAN HEAD8460 BRIGHAM CITY8785 BRYCE CANYON CITY8970 BULLFROG9150 BURMESTER9340 BURRVILLE9890 CAINEVILLE10000 CALLAO10330 CANNONVILLE10440 CARBONVILLE10660 CASTLE DALE11000 CASTLE VALLEY11320 CEDAR CITY11540 CEDAR FORT11440 CEDAR HILLS11870 CENTERFIELD11980 CENTERVILLE12090 CENTRAL12260 CENTRAL VALLEY12420 CHARLESTON12640 CHESTER12970 CIRCLEVILLE13190 CLARKSTON13300 CLAWSON13520 CLEAR CREEK13850 CLEARFIELD14070 CLEVELAND14290 CLINTON14400 CLIVE14840 COALVILLE

15060 COLLINSTON15720 COPPERTON15830 CORINNE15940 CORNISH16270 COTTONWOOD HEIGHTS16600 COVE16930 CRESCENT JUNCTION17260 CROYDON18090 DAMMERON VALLEY18140 DANIEL18910 DELTA19020 DESERET19680 DEWEYVILLE20120 DRAPER20340 DUCHESNE20450 DUGWAY20780 DUTCH JOHN20810 EAGLE MOUNTAIN20890 EAST CARBON21880 ECHO21990 EDEN22210 ELBERTA22370 ELK RIDGE22540 ELMO22650 ELSINORE22760 ELWOOD22870 EMERY23200 ENOCH23420 ENTERPRISE23530 EPHRAIM23640 ERDA23750 ESCALANTE23860 ESKDALE23970 ETNA24080 EUREKA24410 FAIRFIELD24630 FAIRVIEW24740 FARMINGTON24850 FARR WEST25070 FAYETTE25180 FERRON25290 FIELDING25510 FILLMORE26610 FORT DUCHESNE26720 FOUNTAIN GREEN26940 FRANCIS27105 FREEDOM27270 FREMONT27490 FRUIT HEIGHTS27600 FRUITLAND27765 GANDY27930 GARDEN CITY28150 GARLAND28260 GARRISON28810 GENOLA29360 GLENDALE29580 GLENWOOD30130 GOSHEN31120 GRANTSVILLE31670 GREEN RIVER31780 GREENVILLE32000 GREENWICH

32330 GROUSE CREEK32440 GROVER32550 GUNLOCK32660 GUNNISON33040 HAMILTONS FORT33100 HANKSVILLE33210 HANNA33540 HARRISVILLE33760 HATCH34200 HEBER34530 HELPER34640 HENEFER34750 HENRIEVILLE34970 HERRIMAN35135 HIDEOUT35190 HIGHLAND35300 HILDALE35740 HINCKLEY35960 HOLDEN36070 HOLLADAY36290 HONEYVILLE36400 HOOPER36620 HOWELL36730 HOYTSVILLE36950 HUNTINGTON37060 HUNTSVILLE37170 HURRICANE37390 HYDE PARK37500 HYRUM37610 IBAPAH37680 INDEPENDENCE37720 INDIANOLA38710 IVINS39030 JENSEN39150 JERICHO39370 JOSEPH39590 JUNCTION39810 KAMAS39920 KANAB40030 KANARRAVILLE40250 KANOSH40360 KAYSVILLE40470 KEARNS41020 KENILWORTH41240 KIMBALL JUNCTION41350 KINGSTON41515 KNOLLS41680 KOOSHAREM43110 LA SAL43440 LA VERKIN42010 LAKE POINT42230 LAKE SHORE42560 LAKETOWN42890 LAPOINT43660 LAYTON43880 LEAMINGTON44100 LEEDS44320 LEHI44650 LEVAN44760 LEWISTON44870 LIBERTY45090 LINDON

Crash-level Fields

City (continued...)

57630 PALMYRA57740 PANGUITCH57850 PARADISE57960 PARAGONAH58070 PARK CITY58290 PARK VALLEY58510 PAROWAN58730 PAYSON59170 PENROSE59280 PEOA59390 PERRY59720 PETERSON60270 PINE VALLEY60710 PLAIN CITY60930 PLEASANT GROVE61040 PLEASANT VIEW61260 PLYMOUTH61590 PORTAGE61700 PORTERVILLE62030 PRICE62140 PROMONTORY62360 PROVIDENCE62470 PROVO62910 RANDLETT63020 RANDOLPH63240 REDMOND63570 RICHFIELD63680 RICHMOND64120 RIVER HEIGHTS64010 RIVERDALE64230 RIVERSIDE64340 RIVERTON64560 ROCKVILLE64615 ROCKY RIDGE64670 ROOSEVELT64890 ROSETTE65110 ROY65240 RUSH VALLEY65770 SALEM65880 SALINA67000 SALT LAKE CITY67400 SAMAK67440 SANDY67660 SANTA CLARA67770 SANTAQUIN67825 SARATOGA SPRINGS67880 SCIPIO67990 SCOFIELD68210 SEVIER68320 SHARP68540 SHIVWITS68650 SIGURD69640 SMITHFIELD69970 SNOWVILLE70190 SNYDERVILLE70850 SOUTH JORDAN70960 SOUTH OGDEN71070 SOUTH SALT LAKE71180 SOUTH WEBER71290 SPANISH FORK71730 SPRING CITY72170 SPRING LAKE

71840 SPRINGDALE72280 SPRINGVILLE65330 ST GEORGE72720 STANSBURY PARK72940 STERLING73050 STOCKTON74040 SUMMIT74370 SUNNYSIDE74480 SUNSET74810 SYRACUSE74920 TABIONA75140 TALMAGE75360 TAYLORSVILLE75470 TEASDALE75800 THATCHER76265 TICABOO76680 TOOELE76900 TOQUERVILLE77010 TORREY77120 TREMONTON77230 TRENTON77450 TRIDELL77560 TROPIC77670 TROUT CREEK 77780 UCOLO77890 UINTAH79870 VENICE80090 VERNAL80200 VERNON80310 VEYO80420 VINEYARD80530 VIRGIN80860 WALES80970 WALLSBURG81190 WANSHIP81410 WARREN81960 WASHINGTON82070 WASHINGTON TERRACE82510 WELLINGTON82620 WELLSVILLE82730 WENDOVER82840 WEST BOUNTIFUL82930 WEST HAVEN82950 WEST JORDAN83390 WEST POINT83470 WEST VALLEY CITY83720 WEST WEBER83910 WHITE CITY84100 WHITE MESA VILLAGE84160 WHITEROCKS84710 WILLARD85040 WOODLAND85050 WOODLAND HILLS85260 WOODRUFF85370 WOODS CROSS

45530 LOA45860 LOGAN46135 LUND46410 LYMAN46520 LYNN46740 LYNNDYL47180 MAESER47290 MAGNA47620 MANILA47730 MANTI47840 MANTUA47950 MAPLETON48170 MARION48280 MARRIOTT-SLATERVILLE48610 MARYSVALE48720 MAYFIELD48830 MEADOW49160 MENDON49380 MEXICAN HAT49710 MIDVALE49820 MIDWAY49930 MILBURN50040 MILFORD50150 MILLCREEK50260 MILLS50370 MILLVILLE50590 MINERSVILLE50700 MOAB50865 MODENA51140 MONA51360 MONROE51470 MONTEZUMA CREEK51580 MONTICELLO51690 MONUMENT VALLEY51910 MORGAN52130 MORONI52680 MOUNT CARMEL53010 MOUNT PLEASANT52460 MOUNTAIN GREEN52570 MOUNTAIN HOME53230 MURRAY53340 MYTON53560 NAPLES54110 NEOLA54220 NEPHI54440 NEW HARMONY54330 NEWCASTLE54550 NEWTON54660 NIBLEY54990 NORTH LOGAN55100 NORTH OGDEN55210 NORTH SALT LAKE55430 OAK CITY55650 OAKLEY55815 OASIS55980 OGDEN56750 OPHIR56860 ORANGEVILLE57080 ORDERVILLE57300 OREM57410 OURAY0 OUTSIDE CITY LIMITS

Crash-level Fields

Weather Condition

1 Daylight2 Dark - Lighted3 Dark - Not Lighted4 Dark - Unknown Lighting5 Dawn6 Dusk99 Unknown

Light Condition

1 Clear2 Cloudy3 Rain4 Snowing5 Blowing Snow6 Sleet, Hail7 Fog, Smog8 Severe Crosswinds9 Blowing Sand, Soil, Dirt (legacy code)99 Unknown

Roadway Surface Condition

1 Dry2 Wet3 Snow4 Slush5 Ice/Frost6 Water (standing, moving)7 Mud8 Sand, Dirt, Gravel (legacy code)9 Oil10 Dirt11 Gravel12 Sand97 Other*99 Unknown

0 No Special Feature/Junction1 Bridge (overpass/underpass)2 Railroad Crossing3 Business Drive4 Farm/Residential Drive5 Alley6 Crossover in Median7 On-Ramp Merge Area (Acceleration Lane)8 Off-Ramp Diverge Area (Deceleration Lane)9 On-Ramp10 Off-Ramp20 4-Leg Intersection21 T-Intersection22 Y-Intersection23 5-Leg or More Intersection24 Roundabout/Traffic Circle25 Ramp Intersection With Crossroad26 Multi Use Path/Trail Intersection97 Other*99 Unknown

Roadway Junction/Feature

Crash-level Fields

Pavement Type

1 Concrete2 Asphalt (blacktop)3 Gravel,Stone4 Dirt5 Brick,Block97 Other*99 Unknown

First Harmful Event7 Overturn/Rollover8 Cargo Equipment Loss or Shift9 Jacknife10 Fire/Explosion11 Immersion12 Fell/Jumped From Motor Vehicle19 Other Non-Collision*20 Collision With Other Motor Vehicle in Transport21 Collision With Parked Motor Vehicle22 Pedestrian23 Pedacycle24 Other Non-Motorist*25 Animal - Wild26 Animal - Domestic27 Work Zone/Maintenance Equipment28 Freight Rail29 Light Rail30 Passenger Heavy Rail31 Thrown or Fallen Object32 Collision Between Motor Vehicle in Transport and Vehicle Cargo/Part or Object Set in Motion by Motor Vehicle39 Other Non-Fixed Object*40 Guardrail41 Concrete Barrier42 Cable Barrier43 Crash Cushion44 Guardrail End Section45 Concrete Sloped End Section46 Cable Barrier End Section47 Access Control Cable (legacy code)48 Bridge Rail49 Bridge Pier or Support50 Bridge Overhead Structure51 Traffic Sign Support52 Delineator Post53 Other Post, Pole or Support54 Utility Pole/Light Support55 Traffic Signal Support56 Culvert57 Ditch58 Embankment59 Snow Bank60 Tree/Shrubbery61 Mailbox/Fire Hydrant (legacy code)62 Fence63 Curb64 Fire Hydrant65 Mailbox66 Building67 Utility Box68 Other Traffic Barrier*69 Other Fixed Object*

Crash-level Fields

Location of First Harmful Event

1 On Roadway2 Shoulder (legacy code)3 Median4 Gore5 Roadside (outside of shoulder)6 In Parking Lane or Zone (Within Trafficway)7 Off Roadway, Location Unknown8 Outside Trafficway9 Parking Lot Aisle or Stall10 Quasi-public Road or Parking Lot Way11 Shoulder, Left Side12 Shoulder, Right Side13 Separator/Traffic Island99 Unknown

Roadway Contributing Circumstances

0 None1 Debris2 Rut, Hole, Bump3 Road Surface Condition (wet, icy, snow, slush, etc.)4 Work Zone (construction/maintenance/utility)5 Worn, Travel-Polished Surface6 Traffic Control Device (inoperative, missing, or obsecured)7 Shoulder (none, low, soft, high)8 Animal Caused Evasive Action9 Non-Motorist Caused Evasive Action10 Non-Contact Vehicle Caused Evasive Action11 Prior Crash12 Emergency/Maintenance/Tow Vehicle Displaying Lights Prior to Crash13 HOV/Express Lane Related14 Obstruction in Roadway15 Related to a Bus Stop16 School Bus Involved17 Traffic Incident (not including a prior crash)97 Other*99 Unknown

Work Zone Type?

Work Zone?

Workers Present?

1 Yes2 No3 Unknown

1 Yes2 No3 Unknown

1 2 3 4 96 97 99

Lane ClosureLane Shift/CrossoverWork on Shoulder or MedianIntermittent or Moving WorkNot Applicable/No Work ZoneOther*Unknown

Crash-level Fields

1 2 3 4 5 96 99

Before the First Work Zone Warning SignAdvanced Warning Area (after the first warning sign, but before the work area)Transition Area (where lanes are shifted or tapered for lane closure)Activity Area (adjacent to actual work area, whether workers and equipment were present or not)Termination Area (after the activity area, but before traffic resumes normal conditions)Not Applicable/No Work ZoneUnknown

Work Zone Location

Vehicle-Level Fields

Motor Vehicle Body Type

1 Passenger Car2 Passenger Car (4 door) (legacy code)3 Station Wagon (legacy code)4 Pickup5 Sport Utility Vehicle6 Van or Mini Van (legacy code)7 Single Unit Truck8 Single Unit Truck (3 or more axles) (legacy code)9 Truck Tractor11 Heavy Truck Other12 Motorcycle (legacy code)13 School Bus14 Bus/Motorcoach (not school) (legacy code)15 Farm Equipment (tractor, combine, etc.)16 Motorized Scooter/Moped/Motorized Bicycle, etc.17 Off Road Vehicle (snowmobile, ATV, etc.) (legacy code)18 RV/Motor Home20 ATV - Street Legal21 ATV/OHV - Off Road22 Motorcycle (2 wheels)23 Motorcycle (3 wheels)24 Cargo Van25 Passenger Van (


Special Function of Motor Vehicle

0 None1 Law Enforcement - Emer2 Law Enforcement - Non-Emer3 Ambulance - Emer4 Ambulance - Non-Emer5 Fire - Emer6 Fire - Non-Emer7 Snowplow - in Use8 Tow Truck - in Use9 Roadway/Maintenance - in Use10 Mail Carrier11 Military12 Public Utility13 Incident Management14 Taxi15 Electronic Ride-hailing Vehicle- In Use 16 RideShare99 Unknown

Vehicle Area of Initial Impact

0 Impact, No Damage1 Passenger Side Front2 Passenger Side Door3 Passenger Side4 Pass Side Rear Door5 Passenger Side Rear6 Rear7 Driver Side Rear8 Driver Side Rear Door9 Driver Side10 Driver Side Door11 Driver Side Front12 Front13 Top (roof)14 Undercarriage15 Damage, No Impact16 No Impact, No Damage17 Cargo Loss99 Unknown

Location of Damaged Area(s)

0 Impact, No Damage1 Passenger Side Front2 Passenger Side Door3 Passenger Side4 Pass Side Rear Door5 Passenger Side Rear6 Rear7 Driver Side Rear8 Driver Side Rear Door9 Driver Side10 Driver Side Door11 Driver Side Front12 Front13 Top (roof)14 Undercarriage15 Damage, No Impact16 No Impact, No Damage17 Cargo Loss99 Unknown


Vehicle Extent of Damage

0 None1 Minor Damage2 Functional Damage3 Disabling Damage99 Unknown

Direction of Vehicle Travel

1 Northbound2 Southbound3 Eastbound4 Westbound5 Not On Roadway (also for parked motor vehicle)96 Not Applicable (immobile from previous crash, stuck, etc)99 Unknown

Vehicle Contributing Circumstances

0 None1 Brakes2 Steering3 Power Train4 Suspension5 Tires6 Exhaust7 Headlights8 Signal Lights9 Tail Lights10 Horn (legacy code)11 Windows/Windshield12 Wheels13 Truck Coupling/Trailer Hitch/Safety Chains14 Cargo15 Fuel System (legacy code)16 Mirrors17 Wipers18 Body, Doors, Hood97 Other*99 Unknown

Vehicle Maneuver

1 Straight Ahead2 Backing3 Changing Lanes4 Overtaking/Passing5 Turning Right6 Turning Left7 Making U-turn8 Leaving Traffic Lane9 Entering Traffic Lane10 Stopped in Traffic Lane11 Slowing in Traffic Lane12 Mechanically Disabled in Traffic Lane13 Parked14 Parking Maneuvers15 Negotiating a Curve16 Starting to Move in Traffic Lane17 Merging97 Other*99 Unknown


Traffic Control Device

0 None1 Traffic Control Signal2 Flashing Traffic Control Signal3 Stop Sign4 Yield Sign5 Warning Sign6 Person (including flagger, officer, crossing guard, etc.)7 HOV Lane (legacy code)8 Ramp Metering - Active9 School Zone - Inactive10 School Zone - Active11 Railroad Crossing - No Signal12 Railroad Crossing - Signal/Gate13 Lane Use Control Signal97 Other*99 Unknown

Roadway Description

1 Two-Way, Not Divided2 Two-Way, Not Divided With a Continuous Left Turn Lane3 Two-Way, Divided, Unprotected Median4 Two-Way, Divided, Positive Median Barrier5 One-Way6 Parking Lot Aisle/Stall7 Quasi-public Road or Parking Lot Way99 Unknown

Horizontal Alignment

1 Straight2 Curve (legacy code)3 Curve Left4 Curve Right99 Unknown

Vertical Alignment

1 Level2 Grade3 Hillcrest4 Sag (bottom)5 Uphill6 Downhill99 Unknown

Vehicle Estimated Damage

0 No Damage1 $1-$14992 $1500 or more

Towed Status

1 Not Towed2 Towed/Disabled3 Towed/Impounded4 Towed Other

Towed Status1 No2 Yes


Posted Speed

5 5 MPH10 10 MPH15 15 MPH20 20 MPH25 25 MPH30 30 MPH35 35 MPH40 40 MPH45 45 MPH50 50 MPH55 55 MPH60 60 MPH65 65 MPH70 70 MPH75 75 MPH80 80 MPH96 Not Applicable99 Unknown

Vehicle Posted Advisory Speed

5 5 MPH10 10 MPH15 15 MPH20 20 MPH25 25 MPH30 30 MPH35 35 MPH40 40 MPH45 45 MPH50 50 MPH55 55 MPH60 60 MPH65 65 MPH70 70 MPH75 75 MPH80 80 MPH96 Not Applicable99 Unknown

Vehicle Speed Estimated By0 None1 Officer2 Driver3 Passenger4 Witness5 Crash Reconstruction


Sequence of Events

1 Ran Off Road Right (legacy code)2 Ran Off Road Left (legacy code)3 Crosssed Median/Centerline (legacy code)4 Equipment Failure (tire, brakes, etc.) (legacy code)5 Separation of Units (legacy code)6 Downhill Runaway (legacy code)7 Overturn/Rollover8 Cargo Equipment Loss or Shift9 Jacknife10 Fire/Explosion11 Immersion12 Fell/Jumped From Motor Vehicle19 Other Non-Collision*20 Collision With Other Motor Vehicle in Transport21 Collision With Parked Motor Vehicle22 Pedestrian23 Pedacycle24 Other Non-Motorist*25 Animal - Wild26 Animal - Domestic27 Work Zone/Maintenance Equipment28 Freight Rail29 Light Rail30 Passenger Heavy Rail31 Thrown or Fallen Object32 Collision Between Motor Vehicle in Transport and Vehicle Cargo/Part or Object Set in Motion by Motor Vehicle39 Other Non-Fixed Object*40 Guardrail41 Concrete Barrier42 Cable Barrier43 Crash Cushion44 Guardrail End Section45 Concrete Sloped End Section46 Cable Barrier End Section47 Access Control Cable (legacy code)48 Bridge Rail49 Bridge Pier or Support50 Bridge Overhead Structure51 Traffic Sign Support52 Delineator Post53 Other Post, Pole or Support54 Utility Pole/Light Support55 Traffic Signal Support56 Culvert57 Ditch58 Embankment59 Snow Bank60 Tree/Shrubbery61 Mailbox/Fire Hydrant (legacy code)62 Fence63 Curb64 Fire Hydrant65 Mailbox66 Building67 Utility Box68 Other Traffic Barrier*69 Other Fixed Object*80 Crosssed Centerline81 Crossed Median82 End Departure (T-intersection, dead-end, etc.)83 Downhill Runaway84 Equipment Failure (blown tire, brake failure, etc.)

85 Ran Off Road Left86 Ran Off Road Right87 Reentering Roadway88 Separation of Units96 Not Applicable (used only to fill unused box(es))


Most Harmful Event

7 Overturn/Rollover8 Cargo Equipment Loss or Shift9 Jacknife10 Fire/Explosion11 Immersion12 Fell/Jumped From Motor Vehicle19 Other Non-Collision*20 Collision With Other Motor Vehicle in Transport21 Collision With Parked Motor Vehicle22 Pedestrian23 Pedacycle24 Other Non-Motorist*25 Animal - Wild26 Animal - Domestic27 Work Zone/Maintenance Equipment28 Freight Rail29 Light Rail30 Passenger Heavy Rail31 Thrown or Fallen Object32 Collision Between Motor Vehicle in Transport and Vehicle Cargo/Part or Object Set in Motion by Motor Vehicle39 Other Non-Fixed Object*40 Guardrail41 Concrete Barrier42 Cable Barrier43 Crash Cushion44 Guardrail End Section45 Concrete Sloped End Section46 Cable Barrier End Section47 Access Control Cable (legacy code)48 Bridge Rail49 Bridge Pier or Support50 Bridge Overhead Structure51 Traffic Sign Support52 Delineator Post53 Other Post, Pole or Support54 Utility Pole/Light Support55 Traffic Signal Support56 Culvert57 Ditch58 Embankment59 Snow Bank60 Tree/Shrubbery61 Mailbox/Fire Hydrant (legacy code)62 Fence63 Curb64 Fire Hydrant65 Mailbox66 Building67 Utility Box68 Other Traffic Barrier*69 Other Fixed Object*

Vehicle-Level Fields (Large Vehicles/Hazardous Materials)

GCWR/GVWR

1 10,000 lbs OR LESS2 10,001 - 26,000 lbs3 MORE THAN 26,000 lbs

Hazardous Materials Placard Displayed

1 Yes2 No

Hazardous Materials Released

1 Yes2 No

Description of Cargo0 None (legacy code)1 Agriculture Farm Supplies2 Beverages3 Building Materials4 Chemicals5 Coal, Coke6 Commodities, Dry Bulk7 Concrete8 Construction9 Drive-Away, Tow-Away10 Fresh Produce11 Garbage, Refuse, Trash12 General Freight13 Grain, Feed, Hay14 Household Goods15 Intermodal Containers16 Liquids Gasses17 Livestock18 Livestock Containers19 Logs, Poles, Beams, Lumber20 Machinery, Large Objects21 Meat22 Metal23 Mobile Home24 Motor Vehicles25 Oilfield Equipment26 Ore27 Paper Products28 Passengers29 Radioactive30 Refrigerated Food31 Rock, Sand, Gravel32 Salt33 US Mail34 Utilities35 Water Well97 Other*99 Unknown

Vehicle-Level Fields (Large Vehicles/Hazardous Materials)

Purpose of Use

GovernmentPersonalInterstateIntrastate

Vehicle Cargo Body Type

1 Van/Enclosed Box2 Hopper (grain,gravel,etc)3 Bus/Van (seats for 9 -15 people, including driver)4 Bus (Seats more than 15 people, including driver)5 Intermodal Container Chassis6 Auto Transporter7 Concrete Mixer8 Garbage/Refuse9 Flatbed10 Cargo Tank11 Pole12 Log Truck13 Dump96 Not Applicable97 Other*99 Unknown

Person-Level Fields

Person Type1 Driver2 Passenger3 Pedestrian4 Pedalcyclist5 Other Pedestrian (wheelchair, skater, personal conveyance, etc.)*6 Occupant of a Non-Motor Vehicle Transportation Device (person riding on animal or animal drawn conveyance, injured train occupant)*24 Witness25 Owner97 Other*99 Unknown

Sex

M MaleF FemaleU Unknown

Injury Level

1 No injury2 Possible injury3 Suspected Minor Injury4 Suspected Serious Injury5 Fatal

Injury Level0 None1 Head2 Face3 Neck4 Chest5 Abdomen/Pelvis6 Spine7 Upper Extremity8 Lower Extremity99 Unknown

Transported By

1 Not Transported2 EMS Ground3 EMS Air4 Law Enforcement5 Private Vehicle97 Other*99 Unknown

Person-Level Fields

Transported To

0 Not Transported2 Salt Lake Regional Med Ctr3 LDS4 St. Marks5 South Davis Community Hospital (Bountiful)6 University (U of U)7 Davis Hospital and Medical Center (Layton)8 PHC Pioneer Valley9 Veterans Administration10 McKay-Dee Center11 Ogden Regional Medical Center12 Delta Community Medical Center13 American Fork14 Central Valley Medical Center15 Mountain View (Payson)16 Utah Valley Regional Med Ctr17 Logan Regional18 Beaver Valley (Beaver)19 Valley View Medical Center20 Gunnison Valley21 Milford Valley Memorial22 San Pete Valley (Mt. Pleasant)23 Garfield Memorial (Panguitch)24 Sevier Valley25 Dixie Regional (St George)26 Castleview27 Bullfrog Medical Clinic29 Uintah Basin Medical Center30 Uintah County31 Brigham City Community Columb.32 Tooele Valley Regional33 Other (med clinics not listed)*34 Primary Childrens36 Allen Memorial (Moab)37 Carbon Medical Service38 Fillmore Community Medical Ctr39 Kane County (Kanab)40 Bear River Valley (Tremonton)41 Wasatch County (Heber)42 Lakeview (Bountiful) Columbia44 San Juan Regional (Monticello)45 Fillmore Clinic46 Green River Medical Center47 Heber Valley Clinic48 Price Medical Center49 Wasatch Medical Clinic (Heber)50 Personal Doctor51 Alta View52 Hill Air Force Base53 Ashley Valley M.C. (Vernal)54 Blanding Clinic55 Southwest Emergency (W Jordan)56 Monument Valley (San Juan)57 Orem Community58 PHC Regional (Formerly FHP)59 Park City Family Health Center60 St. Marys61 Emery Med Ctr (Castledale)62 BYU Health Clinic63 Crestwood Med Ctr (Kaysville)64 Herfordshire Clinic (Roy)65 Hurricane Clinic

66 Wendover Clinic67 Timpanogos69 Mountain West Medical Center70 Jordan Valley (not Holy Cross)71 Medical Examiner72 Cache Valley Specialty74 Bear Lake Community Health (Garden City)77 Intermountain Medical Center78 Kamas Clinic79 Intermountain Ephraim Clinic80 Riverton Hospital81 Lone Peak Medical82 Park City Medical Center83 Davis Hospital (Weber Campus)84 Out of State Hospital/Medical Center*96 Not Applicable97 Other (Not a Hospital or Medical Clinic)*99 Unknown

Person-Level Fields

Seating Position

11 Front Left, Motorcycle Driver12 Front Center13 Front Right18 Front Row Other21 2nd Row Left, Motorcycle Passenger22 2nd Row Center23 2nd Row Right28 2nd Row Other31 3rd Row Left32 3rd Row Center33 3rd Row Right38 3rd Row Other41 4th Row Left42 4th Row Center43 4th Row Right48 4th Row Other50 Sleeper Section of Cab (Truck)51 Other passenger in enclosed passenger or cargo area52 Other passenger in unenclosed passenger or cargo area54 Trailing unit55 Riding on vehicle exterior56 Seating Position 11, Not Driver57 Right Side Driver60 Non Motorist97 Other99 Unknown

Safety Equipment Used

0 None1 Lap & Shoulder belt2 Shoulder belt only3 Lap Belt Only4 Child Restraint - Forward Facing5 Child Restraint - Rear Facing6 Booster Seat7 Helmet worn (legacy code)8 Helmet & Other (legacy code)9 Child Restraint - Other Type*10 Motorcycle Helmet, DOT-Compliant 11 Helmet, Other Than DOT-Compliant Motorcycle Helmet12 Helmet, Unknown If DOT-Compliant13 Stretcher14 Wheelchair97 Other*99 Unknown

Any Indication of Improper Use

1 Yes2 No96 Not Applicable (not restrained)99 Unknown (Due to extent of damage/evidence destroyed)

Person-Level Fields

Airbag Deployed

0 No Air Bag1 Not Deployed2 Deployed - Front3 Deployed - Side4 Deployed - Other (knee, air belt, etc.)5 Deployed - Combination6 Deactivated (legacy code)7 Missing/Previously Deployed8 Deployed - Curtain99 Deployment Unknown

Ejection

0 Not Ejected1 Totally Ejected2 Partially Ejected96 Not Applicable(motorcycle, snowmobile, pedestrian, pedalcyclist, etc.)99 Unknown

Ejection Path

1 Windshield2 Side Window/Door3 Rear Window/Door96 Not Applicable97 Other*99 Unknown

Cause for Ejection

1 Improper Restraint2 Restraint Failure3 Seating compartment destroyed4 Severity of crash

Extrication

1 Not Extricated2 Extricated99 Unknown

Person-Level Fields (Driver Only)

Driver License State

AL Alabama AK Alaska AB Alberta AZ Arizona AR Arkansas BC British Columbia CA California CO Colorado CT Connecticut DE Delaware DC District of Columbia FL Florida GA Georgia HI Hawaii ID Idaho IL Illinois IN Indiana II International License (other than Canada or Mexico)IA Iowa KS Kansas KY Kentucky LA Louisiana ME Maine MB Manitoba MD Maryland MA Massachusetts MX Mexico MI Michigan MN Minnesota MS Mississippi MO Missouri MT Montana NB Nebraska NV Nevada NB New Brunswick NH New Hampshire NJ New Jersey NM New Mexico NY New York NF Newfoundland NC North Carolina ND North Dakota NT Northwest Territory NA Not ApplicableNO Not LicensedNS Nova Scotia NU Nunavut OH Ohio OK Oklahoma ON Ontario OR Oregon ZZ Other*PA Pennsylvania PE Prince Edward Island QC Quebec RI Rhode Island SK Saskatchewan SC South Carolina SD South Dakota TN Tennessee TX Texas US United States Government

UT Utah VT Vermont VA Virginia WA Washington WV West Virginia WI Wisconsin WY Wyoming XX UnknownYT Yukon Territory


Driver License Class

A Commercial over 26,000 w/towed unit over 10,000 GVWRB Commercial over 26,000 w/towed unit under 10,000 GVWRC Commercial under 26,000D Private or other vehicles - not CommercialX Learner or Mobility Vehicle Permit or Skeleton

Driver License Endorsements

H Hazardous MaterialsM MotorcyclesN TankersP PassengersS School BusT Doubles & Triple TrailersX Hazmat & TankersZ Taxicab

Driver License Status

0 Not Licensed1 Valid License2 Canceled or Denied3 Disqualified (CDL)4 Expired5 Revoked6 Suspended7 Learner's Permit8 Temporary/Limited9 Driving Privilege Card99 Unknown

Charge Status

1 YES2 NO3 PENDING99 UNKNOWN

Driver Condition

1 Appearing Normal2 Illness/Medical3 Fatigue/Asleep4 Exceeded HOS Limits (legacy code)5 Under the Influence of Alcohol/Drugs/Medications6 Emotional Prior to Crash (depressed/angry/disturbed/etc.)7 Physically Impaired97 Other*99 Unknown

Speeding Related

1 No2 Yes, Exceeded Speed Limit3 Yes, Too Fast for Conditions4 Yes, Street Racing99 Unknown


Driver Contributing Circumstances

0 None1 Exceeded Posted Speed Limit (legacy code)2 Too Fast for Condtions (legacy code)3 Failed to Yield Right-of-Way4 Failed to Keep in Proper Lane5 Unsafe Lane Change6 Over-Correcting/Over-Steering7 Disregard Traffic Signs8 Disregard Traffic Signals9 Disregard Road Markings10 Swerved or Evasive Action11 Followed too Closely12 Reckless/Aggressive (legacy code)13 Wrong Side/Wrong Way14 Improper Parking/Stopping15 Ran Off Road16 Improper Backing17 Improper Signal (legacy code)18 Improper Passing19 Improper Turn20 Hit and Run (legacy code)21 Street Racing (legacy code)22 Reckless Driving23 Aggressive Driving/Road Rage97 Other*99 Unknown

Driver Distraction Action

0 Not Distracted1 Talking/Listening2 Manually Operating (texting,dialing,playing game,etc.)3 Other Action*9 Unknown

Driver Distracted Source

0 None (legacy code)1 Cell Phone (legacy code)2 Audio (using vehicle controls)3 Other Electronic Device (legacy code)4 Passenger(s)5 Texting (legacy code)6 TV Monitor (legacy code)7 Other Inside Distraction* (legacy code)8 Other Outside Distraction* (legacy code)9 Hand-Held Mobile Phone10 Hands-Free Mobile Phone11 Audio (using vehicle controls)12 Climate Control13 Vehicle-Integrated Device14 Other Electronic Device*15 Animal (inside vehicle)16 Food/Drink17 Grooming18 Other Inside Distraction*19 Other Outside Distraction*96 Not Applicable (Not Distracted)97 Other* (legacy code)99 Unknown


Visual Contributing Circumstances

0 None1 Weather Condition2 Physical Obstruction3 Windshield Broken or Improperly Cleaned/Cleared4 Trees, Crops, Bushes, Other Vegetation5 Parked Vehicle(s)6 Signs, Billboards, etc.7 Moving Vehicle(s)8 Building9 Guardrail/Barrier10 Glare11 Smoke12 Rain, Snow, Fog13 Blowing Sand, Soil, Dirt14 Curve, Hill, or Other Roadway Design Feature15 Splash or Spray of Passing Vehicle16 Inadequate Defrost System17 Obstruction Interior to Vehicle97 Other*99 Unknown

Attempted Avoidance Maneuver

0 No Avoidance Maneuver1 Accelerating2 Accelerating and Steering Left3 Accelerating and Steering Right4 Braking5 Braking and Steering Left6 Braking and Steering Right7 Braking and Unknown Steering Direction8 Releasing Brakes9 Steering Left10 Steering Right97 Other Actions*99 Unknown

Alcohol/Drug Use Suspected

0 None1 Alcohol2 Drugs3 Both99 Unknown

Alcohol/Drug Test

0 Not Given1 Refused (legacy code)2 Alcohol3 Drug4 Both5 Taken to M.E.97 Other* (legacy code)

Test Results

1 Alcohol-Pos2 Drug-Pos3 Both-Pos4 Negative5 Pending96 Not Applicable/No Test


Drug Positive Test Results

1 Cannabinoid2 Narcotic3 Depressant4 Stimulant5 Hallucinogen6 Phencyclidine (PCP)7 Inhalant8 Other Drug*9 Positive Drug Test, Unknown Drug Type

Person-Level Fields (Non-Motorists)

Non-Motorist Action

1 Entering or Crossing Road2 Walking/Cycling Along Roadway with Traffic3 Walking/Cycling Along Roadway Against Traffic4 Waiting to Cross Roadway5 Walking/Cycling on Sidewalk6 Working in Trafficway7 Working on Vehicle8 Pushing Motor Vehicle9 In Roadway-other*10 Adjacent to Roadway (e.g. Shoulder, Median)11 Going to or from School (K-12)12 Leaving/Approaching Disabled Vehicle13 Entering Vehicle96 Not Applicable97 Other*99 Unknown

Non-Motorist Contributing Circumstances

0 None1 Improper Crossing2 Dart/Dash3 Wrong Side of Road4 Not Visible5 Inattentive6 Failure to Obey Traffic Signs, Signals, or Officer7 Failure to Yield Right-of-Way8 In Roadway Improperly (Lying, Kneeling, Standing, etc.)9 Improper Turn/Merge10 Improper Passing96 Not Applicable (legacy code)97 Other*99 Unknown

Non-Motorist Location

1 Intersection - Marked Crosswalk2 Intersection - Unmarked Crosswalk3 Midblock Crosswalk4 School Crosswalk - Intersection5 School Crosswalk - Midblock6 Travel Lane (not crosswalk or intersection)7 Median/Island8 Shoulder/Roadside9 Island (Legacy code)10 Sidewalk11 Roadside (Legacy code)12 On-Street Bike Lane13 Shared Use Path/Trail14 Outside Right-of-Way15 Inside Building16 Intersection - Not in Crosswalk (marked or unmarked)17 Separated Bike Lane18 Driveway Access96 Not Applicable (Legacy code)97 Other*99 Unknown


Non-Motorist Origin/Destination

1 Going to or from School (K-12)2 Going to or from Transit3 Not Going to/from School or Transit99 Unknown

Non-Motorist Safety Equipment

0 None1 Helmet2 Protective Pads Used (elbow, knee, shin, etc.)3 Reflective Wear/Reflectors4 Lighting97 Other99 Unknown

Incident Responder

1 No2 Yes, EMS3 Yes, Fire4 Yes, Police5 Yes, Tow Operator6 Yes, Transportation - Responding to Incident7 Yes, Transportation - Not Responding to Incident97 Other*99 Unknown

Non-Motorist Condition

1 Appearing Normal2 Illness/Medical3 Fatigue/Asleep4 Physically Impaired5 Under the Influence of Alcohol/Drugs/Medications6 Emotional Prior to Crash (depressed/angry/disturbed/etc.)97 Other*99 Unknown

Non-Motorist Distraction

0 None1 Mobile Phone - Talking/Listening2 Mobile Phone - Manually Operating (texting, dialing, playing game, etc.)3 Other Electronic Device4 Other Non-Motorist5 Audio (radio, cd, etc.)6 Animal7 Food/Drink8 Grooming9 Contact Motor Vehicle Prior to Collision10 Non-Contact Motor Vehicle97 Other*99 Unknown


Alcohol/Drug Use Suspected

0 None1 Alcohol2 Drugs3 Both99 Unknown

Alcohol/Drug Test

0 Not Given1 Refused2 Alcohol3 Drug4 Both5 Taken to M.E.

Test Results

1 Alcohol-Pos2 Drug-Pos3 Both-Pos4 Negative5 Pending96 Not Applicable/No Test

Drug Positive Test Results

1 Cannabinoid2 Narcotic3 Depressant4 Stimulant5 Hallucinogen6 Phencyclidine (PCP)7 Inhalant8 Other Drug*9 Positive Drug Test, Unknown Drug Type

DI 9 State of Utah Investigating

Officer’s Report of Traffic Crash

and Overlay

INVESTIGATING OFFICER'S REPORT OF TRAFFIC ACCIDENT

CASE NODATE OFCRASH:

TIM

E DAY OFWEEK

TIME DLD NO 2000000001Page 1

LE NOTIFIED ARRIVED COMPLETED FIELD DIAGRAM VIDEO PHOTOS1ST SUBMIT TO UDPS LAST SUBMIT TO UDPS GENERATED WORK ZONE? WORKERS?LANESVEHICLESEMS NOTIFIED ARRIVED

of 3DPS CASENUMBER

LONGITUDELATITUDE

WEATHER CONDITION

NON-MOTORIST ACTION

ROAD JURISDICTION

LIGHT CONDITION NON-MOTORIST LOCATION

PAVEMENT TYPE

LOC

AT

ION COUNTY CITY OR TOWN

ROAD, STREET, HWYCRASH OCCURRED

LOCATION ON ROAD,STREET, HWY

MILEPOST

CO

DE

S

SEVERITY

MANNER OF COLLISION

DIA

GR

AM

NA

RR

AT

IVE

UDOT USE ONLYREPORTABLE

tenth(s) of a mile of Mile Post

feet of

miles of

Narrative text added here...

FIRST HARMFUL EVENT

LOCATION OF FIRST HARMFUL EVENTROADWAY JUNCTION/FEATURE

NON-MOTORIST CONTRIBUTING CIRCUMSTANCES

ROADWAY SURFACE CONDITION

ROADWAY CONTRIBUTING CIRCUMSTANCES

WORK ZONE LOCATION

OFFICER'S RANK AND NAME ID # DEPARTMENT CASE NUMBER SUPERVISORDPS CASE NUMBER

WORK ZONE TYPE

Diagram image added here...



TIM

E DAY OFWEEK



of 3DPS CASENUMBER

INJURY LEVEL

NAME / ADDRESS SEXVEH# DOB TRANSPORTED TOAGE BACPHONE

PERSON TYPE TRANSPORTED BYINJURY CAUSE

SAFETY EQUIPMENT EJECTION PATHAIRBAG

INJURY AREA

USED PROPERLY EXTRICATION

SEATING POSITION

Dri

ver

1

INJURY LEVEL


PERSON TYPE TRANSPORTED BY

EJECTION

INJURY CAUSE


INJURY AREA


SEATING POSITION

Pas

sen

ger

1

AGENCY THAT SOLD POLICY

VEH# PLATE STATE EXPIRATION COLOR

DRIVER NAME / ADDRESS

DL NUMBER CLASS ENDORSEMENTS RESTRICTIONS DL EXPIRATION DATE OF BIRTH AGE CHARGES

CARRIER NAME / ADDRESS

US DOT # CVSA INSPECTION # WEIGHT HAZMAT CARGO PURPOSE OF USE

MAKE MODEL YEAR OCC

ESTIMATE

VE

HIC

LE

TRAILING UNITS

CARGO BODY TYPE

AREA OF INITIAL IMPACT

VEHICLE MANEUVERMOST DAMAGED AREA

TRAFFIC CONTROL DEVICE

PHONE

PHONE

PHONE

#1 TRAILER PLATE # STATE EXPIRATION DATE LENGTH #2 TRAILER PLATE # STATE EXPIRATION DATE LENGTH #3 TRAILER PLATE # STATE EXPIRATION DATE LENGTH

ESTIMATED BYIMPACTTRAVELADVISORYPOSTED

SP

EE

D

EFFECTIVE DATE EXPIRATION DATE

POLICY NUMBER PHONE

INSURANCE COMPANY

OPERATING AUTHORITY (ICC)

OWNER NAME / ADDRESS

DISPOSITION TOWED BY

VIN

CDL PRESENTED AT SCENE

1 2 4 Most Harmful Event

1

MOTOR VEHICLE BODY TYPE

VEHICLE EXTENT OF DAMAGEMOST DAMAGED AREA

SPECIAL FUNCTION OF MOTOR VEHICLE

DIRECTION OF VEHICLE TRAVEL

DRIVER CONTRIBUTING CIRCUMSTANCES 1 DRIVER CONTRIBUTING CIRCUMSTANCES 2

VEHICLE CONTRIBUTING CIRCUMSTANCES

APPEARS VALID

EV

EN

T

RELEASED

3


HORIZONTAL ALIGNMENT VERTICAL ALIGNMENT

DL NUMBER CLASS ENDORSEMENTS RESTRICTIONS DL EXPIRATION DATE OF BIRTH AGE CHARGES DRIVER LICENSE STATUS

SPEEDING-RELATED ALCOHOL/DRUG TEST TEST RESULTS DRUG POSITIVE TEST RESULTSALCOHOL / DRUG USE SUSPECTED

DRIVER CONDITION DRIVER DISTRACTED SOURCEDRIVER CONTRIBUTING CIRCUMS 1 VISUAL CONTRIB. CIRCUMST.DRIVER DISTRACTIONDRIVER CONTRIBUTING CIRCUMS 2

ATTEMPTED AVOIDANCE MANEUVER

STATE

EJECTION

INJURY LEVEL


PERSON TYPE TRANSPORTED BYINJURY CAUSE


INJURY AREA


SEATING POSITION

Dri

ver 2

DL NUMBER CLASS ENDORSEMENTS RESTRICTIONS DL EXPIRATION DATE OF BIRTH AGE CHARGES DRIVER LICENSE STATUS

SPEEDING-RELATED ALCOHOL/DRUG TEST TEST RESULTS DRUG POSITIVE TEST RESULTSALCOHOL / DRUG USE SUSPECTED

DRIVER CONDITION DRIVER DISTRACTED SOURCEDRIVER CONTRIBUTING CIRCUMS 1 VISUAL CONTRIB. CIRCUMST.DRIVER DISTRACTIONDRIVER CONTRIBUTING CIRCUMS 2

ATTEMPTED AVOIDANCE MANEUVER

STATE

EJECTION

AGENCY THAT SOLD POLICY

VEH# PLATE STATE EXPIRATION COLOR

DRIVER NAME / ADDRESS

DL NUMBER CLASS ENDORSEMENTS RESTRICTIONS DL EXPIRATION DATE OF BIRTH AGE CHARGES

CARRIER NAME / ADDRESS

US DOT # CVSA INSPECTION # WEIGHT HAZMAT CARGO PURPOSE OF USE

MAKE MODEL YEAR OCC

ESTIMATE

VE

HIC

LE

TRAILING UNITS

CARGO BODY TYPE

AREA OF INITIAL IMPACT

VEHICLE MANEUVERMOST DAMAGED AREA

TRAFFIC CONTROL DEVICE

PHONE

PHONE

PHONE

#1 TRAILER PLATE # STATE EXPIRATION DATE LENGTH #2 TRAILER PLATE # STATE EXPIRATION DATE LENGTH #3 TRAILER PLATE # STATE EXPIRATION DATE LENGTH

ESTIMATED BYIMPACTTRAVELADVISORYPOSTED

SP

EE

D

EFFECTIVE DATE EXPIRATION DATE

POLICY NUMBER PHONE

INSURANCE COMPANY

OPERATING AUTHORITY (ICC)

OWNER NAME / ADDRESS

DISPOSITION TOWED BY

VIN

CDL PRESENTED AT SCENE

1 2 4 Most Harmful Event

2

MOTOR VEHICLE BODY TYPE

VEHICLE EXTENT OF DAMAGEMOST DAMAGED AREA

SPECIAL FUNCTION OF MOTOR VEHICLE

DIRECTION OF VEHICLE TRAVEL

DRIVER CONTRIBUTING CIRCUMSTANCES 1 DRIVER CONTRIBUTING CIRCUMSTANCES 2

VEHICLE CONTRIBUTING CIRCUMSTANCES

APPEARS VALID

EV

EN

T

RELEASED

3

HORIZONTAL ALIGNMENT VERTICAL ALIGNMENT



TIM

E DAY OFWEEK



of 3DPS CASENUMBER

WITNESS 1

WITNESS 2


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