MOTOR VEHICLE CRASH REPORT OVERLAY NO. 1
GENERAL INSTRUCTIONS 1. 2.
North Dakota Department of Transportation Drivers License & Traffic Safety DOT 2356 (Rev.12-2006)
3.
CRASH AND GENERAL INFORMATION
t t t t t t
A. REPORT TYPE 1. Original 2. Supplemental (Send copy of original report with all supplemental reports.)
B. CRASH TYPE 1. Traffic 2. Non-Traffic
3. Non-Reportable
C. CRASH SEVERITY 1. Fatal 2. Injury
3. Property Damage Only
D. HIT AND RUN 1. Yes 2. No (If code "Yes" used for original, then all supplement reports must be "Yes") E. 1. 2. 3.
AGENCY TYPE Highway Patrol City Police County Sheriff
4. BIA 5. Campus PD 6. Military Police
7. Park Ranger
R. 01. 02. 03. 04. 05. 06. 07. 08. 09. 10. 11. 12.
UNIT CONFIGURATION Pass. Car Pickup / Van / Utility Bus (Seats For > 16, Incl. Driver) School Bus Motorhome / Camper Snowmobile All-Terrain Veh. Motorcycle Moped Pedal Cycle Const. Equip. Emergency Vehicle
TRUCK CARGO BODY TYPE Not Applicable Van / Enclosed Box Dry Bulk Cargo Tank Liquid Bulk Cargo Tank Gaseous Bulk Cargo Tank
Train Farm Equipment Modified Vehicle Hit and Run Vehicle Roadway Maintenance Vehicle Other Publicly-Owned Vehicle Pedestrian 2-Axle 6-Tire Single Unit Truck / Stepvan 3 or More Axles Single Unit Truck Single Unit Truck Truck Tractor Unknown Heavy Trucks
2. Double Trailer
05. Flatbed / Platform 06. Dump 07. Concrete Mixer 08. Auto Transporter 09. Garbage / Refuse
U. ANTILOCK BRAKE SYSTEM 0. None 1. Rear Only
F. INTERSECTION TYPE 1. Non-Intersection 3. Four Roads 2. Three Roads 4. Five or More Roads
13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.
3. Triple Trailer
10. Bus (16 Incl. Driver) 11. Combination * 12. Special Permit Load 90. Other * 99. Unknown
2. Front Only
3. Front and Rear
V. ORIGINAL DIRECTION OF TRAVEL
t
t t
t
t t t
RELATION TO ROADWAY On Roadway 5. Outside Shoulder-Left (Includes Ditch) Shoulder 6. Outside Shoulder-Right (Includes Ditch) Median 7. Off Roadway (Location Unknown) Gore 8. Parking Lot Private Property 9. Alley
H. 1. 2. 3. 4.
RELATION TO JUNCTION Non-Junction Intersection Interchange Area Alley / Driveway Access
5. 6. 7. 8.
Entrance / Exit Ramp Railroad Grade Crossing Bridge Intersection Related
I. ROADWAY GEOMETRICS 1. Straight (On Level) 3. Curve (On Level) 2. Straight (On Grade) 4. Curve (On Grade) J. 1. 2. 3. 4.
5. Hill Crest
TRAFFICWAY Not Divided (Two-Way Traffic) Divided Highway (Median Strip Without Barrier) Divided Highway (Median Strip With Barrier) One-Way Trafficway
K. ACCESS CONTROL 1. No Control (Unlimited Access) 2. Full Control (Only Ramp Entry and Exit) L. 1. 2. 3. 4.
ROAD CONDITION Normal Under Construction, Maintenance Soft / Defective Shoulder Obstruction / Flood
M. 1. 2. 3.
SURFACE TYPE Concrete Asphalt Gravel / Scoria
4. Dirt 5. Brick
t
N. SURFACE CONDITION 1. Dry 3. Muddy 2. Wet 4. Snow
t
O. 1. 2. 3.
3. Other *
Debris On Road Reduced Road Width Holes / Ruts / Bumps / Washout Loose Material Surface
IF BRIDGE DECK: 6. Concrete Bridge Deck 7. Asphalt Bridge Deck 8. Metal Bridge Deck 9. Wood Bridge Deck
WEATHER Clear 4. Snow Cloudy 5. Blowing Soil / Snow Rain 6. Sleet / Hail / Freezing Rain
P. LIGHT 1. Daylight 2. Dawn
t
Q. VISUAL OBSTRUCTION 0. None 3. 1. Rain / Snow / Frost on 4. 5. Window 2. Trees / Crops / Sign 6.
SW
8
1
p p
6 5
2
NE 3 E
4
SE
S
X. OBSERVATIONS * 00. None 01. Need Signing 02. Trees / Shrubs / Tall Grass 03. Pavement Marking 04. Hill / Curve 05. Narrow Bridge / Roadway 06. Rough Road 07. Lighting Y. 1. 2. 3.
u
06. RR Crossbucks / Pavement Marking 07. Officer / Flagperson 08. Traffic Signal 09. Yield Sign 10. Barricade 11. Control Not Visible / Broken
08. Traffic Signals 09. Clearance Height 10. Road Maintenance 11. Delineators / Bridge Markings 12. Guardrail 13. Geometrics 14. Speed Limit
MANNER OF COLLISION 4. Sideswipe (Same Direction) Angle 5. Sideswipe (Opposite Direction) Rear-End 6. Rear-to-Rear Head-On
7. Non-Collision With Motor Vehicle in Transport
u
u
u
u
Z. FIRST HARMFUL EVENT
5. 6. 7. 8.
5. Slush 6. Ice / Compacted Snow
t
W 7
W. TRAFFIC CONTROL 00. None 01. Stop Sign 02. No Passing Zone 03. Flashing Beacon 04. RR Signals With Gates 05. RR Signals Only
u
N NW
G. 0. 1. 2. 3. 4.
u
u
S. ATTACHMENTS 0. None 1. Single Trailer T. 00. 01. 02. 03. 04.
USE BLACK INK OR TYPE ONLY COMPLETE ALL BLOCKS UNLESS OTHERWISE DIRECTED EXCEPTIONS ARE LISTED IN APPENDIX A OF THE OFFICERS MANUAL. ALL ITEMS WITH AN ASTERISK (*) MUST BE EXPLAINED IN THE NARRATIVE.
3. Dusk 4. Dark (Lighted)
Building Embankment Hillcrest Parked MV
7. Frost
7. Fog / Smoke / Dust 8. Severe Wind
5. Dark (Not Lighted)
7. MV in Roadway 8. Glare 9. Fog / Smoke / Dust
_ _ (Initial _ _ Collision _ _ _ -_Characterizes _ _ _ _ the _ _crash _ _type. _ Use _ _one_ of_the_ codes _ _ below.) ______u AA. SEQUENCE OF EVENTS (Use up to 3 of the codes below for each vehicle. If necessary, to describe the sequence of accident-related events following the first
_ _ harmful _ _ _event.) _________________________ COLLISION WITH OBJECT - NOT FIXED COLLISION WITH FIXED OBJECT 01. Motor Vehicle in Transport 30. Impact Attenuator 02. Motor Vehicle in Transport in Other Rdwy 31. Bridge / Pier / Abutment 03. Pedestrian 32. Bridge Parapet End 04. Pedal Cycle 33. Bridge Rail 05. Railway Train 34. Guardrail Face 06. Deer 35. Guardrail End 07. Other Large Game 36. Median Barrier 08. Farm Animal 37. Highway Traffic Sign Post 09. Small Animal 38. Overhead Sign Support 10. Parked Motor Vehicle 39. Luminaire / Light Support 11. Other Object (Not Fixed) 40. Utility Post 41. Other Post NON-COLLISION 42. Culvert 20. Overturn / Rollover 43. Curb 21. Fire / Explosion 44. Ditch 22. Immersion 45. Embankment 23. Jackknife 46. Fence 24. Downhill Runaway 47. Mail Box 25. Cargo Loss or Shift 48. Tree 26. Separation of Units 49. Other Fixed Object 27. Ran off Roadway 28. Other Non-Collision
u
u
______________________________ BB. MOST HARMFUL EVENT (If an event following the initial collision causes the most damage, use the codes above. One for each vehicle, if necessary, to identify this most harmful event.) LEAVE BLANK IF SAME AS "Z" ABOVE
u
MOTOR VEHICLE CRASH REPORT OVERLAY NO. 2 OCCUPANT, WITNESS, AND PROPERTY INFORMATION OCCUPANT SEAT POSITION 11. 12. 13. 21. 22. 23. 31. 32. 33. 50.
11 12 13 21 22 23 31 32 33
Front Seat-Left Side (Motorcycle Driver) Front Seat-Middle Front Seat-Right Side Second Seat-Left Side (Motorcycle Passenger) Second Seat-Middle Second Seat-Right Side Third Row-Left Side (Motorcycle Passenger) Third Row-Middle Third row-Right Side Sleeper Section of Cab (Truck)
51. 52. 55. 56. 80. 94. 95. 96. 97. 99.
Passenger in Other Enclosed Passenger or Cargo Area (Non-Trailing Unit) Passenger in Unenclosed Passenger or Cargo Area (Non-Trailing Unit) Riding on Vehicle Exterior (Non-Trailing Unit) Passenger in Trailing Unit Bus Passenger Damage Prop. (Public) Damage Prop. (Private) Pedestrian Witness Unknown
AGE - In Years (Code 00 for infants under 1 year, 99 for unknown.) SEX
M - Male
F - Female
U - Unknown
ALCOHOL/OTHER DRUG INVOLVEMENT (ADI) 0. Neither Alcohol nor Other Drugs Present 1. Yes (Alcohol Present) 2. Yes (Other Drugs Present)
3. Yes (Alcohol and Other Drugs Present) 9. Unknown
ALCOHOL TESTING (AT) 994 Test Refused 995 Test Not Given
0.14 AC is Coded 014 993 Field Sobriety Test Only
996 Test Given ( Results Unknown)
OTHER DRUG TESTING (DT) 0. Not Given 1. No Drugs Reported
2. Drugs Reported (If So, Specify **) 7. Test Given (Results Unknown)
**Identify results for the five regulated substances: Marijuana, Cocaine, Opiates, Amphetamines, & PCP.
SAFETY EQUIPMENT/RESTRAINTS 00. 01. 02. 03. 04. 05. 06. 07.
Not Installed Not in Use Lap Belt Only Shoulder Belt Only or Automatic Belt Improperly Used Lap and Shoulder Belts Automatic Belts (Properly Used) Equipment Failed Helmet Worn
AIR BAG
0. None
INJURY CLASS. 0. None 1. Fatal
98. Not Applicable (Non-Motorist) 99. Restraint Use Unknown
CHILD RESTRAINTS 10. Child Not Restrained 11. Child Safety Seat (Used Properly) 12. Child Safety Seat (Used Improperly)
1. Air Bag Deployed
2. Air Bag Not Deployed
WAS INJURED TAKEN TO MEDICAL FACILITY? No
Yes
2. Disabling 3. Non-Disabling 4. Possible / Claimed
5. Disabling 6. Non-Disabling 7. Possible / Claimed
EJECTED/EXTRICATED 0. Not Applicable 1. Not Ejected 2. Totally Ejected
3. Partially Ejected 4. Trapped / Extricated 5. Trapped / Not Extricated
PROPERTY OWNER NOTIFIED
2. No
AMBULANCE RUN NUMBER
UNIT NUMBER
q
1. Yes
q
q
q
q
q
q
q
q
q
q
q
Do not list operator / pedestrian name and address. List where fatalities and injuries were taken.
q
A Summary By Unit Number, of the Sequence of Actions, Events, Contributing Factors, Citations, and Vehicle Damage.
MOTOR VEHICLE CRASH REPORT OVERLAY NO. 3 ACTION SEQUENCE, CITATIONS, AND DAMAGE TOWED DUE TO DAMAGE
1. Yes
2. No
9. Unknown
2. Moderate
3. Severe
9. Unknown
EXTENT OF DEFORMITY 0. None
1. Minor
DRIVER CONDITION 00. 01. 02. 03. 04. 05. 06. 07.
02
None Center Front Right Front Right Side Right Rear Center Rear Left Rear Left Side
08. 09. 10. 11. 12. 13. 98. 99.
Left Front Top and Windows Under Carriage Submerged Burned Total (All Areas) Other * Unknown
02
03
01 07
04
04 09
08
03
05
01
05
09
06 08
07
06
DRIVER CONDITION 0. Appeared Normal 1. Had Been Drinking
2. Illegal Drug Use 3. Physical Impairment
4. Fatigue 5. Asleep
6. Sick 7. Medication
8. Other * 9. Unknown
EVASIVE ACTION 1. Slowed / Stopped 2. Accelerated
3. Turned Right 4. Turned Left
5. Backed Up 6. Did Nothing
Use the narrative to provide more specific information on Citations / Written Warnings. Following 14. Illegal Parking Improper Turning 98. Other Offense * NOT CONTRIBUTING TO CRASH Improper Backing Overtaking 15. Open Container Wrong Way 16. Driver's License Speeding 17. Left Accident Scene Defective Equipment
CITATIONS/WRITTEN WARNINGS 00. 01. 02. 03. 04. 05. 06.
None DUI (Alcohol) DUI (Drugs) Care Required Careless Driving Failed to Yield Failed to Stop
CONTRIBUTING FACTORS 00. 01. 02. 03. 04. 05. 06. 07.
No Clear Contributing Factor Attention Distracted Vision Obstructed Speed / Too Fast for Conditions Vehicle Mechanical Failure Wrong Way Failed to Yield Following too Close
07. 08. 09. 10. 11. 12. 13.
Use up to two of the codes below for each unit. 08. Weather 09. Defective Equipment 10. Improper Evasive Action 11. Improper Backing / Tuning 12. Improper Overtaking 13. Drove Left of Center 98. Other *
VEHICLE MOVEMENT 01. 02. 03. 04. 05. 06. 07. 08. 09. 10. 11. 12. 13. 14. 15. 16. 17.
Going Straight Turning Left Turning Right Backing Passing Wrong Side of Road Wrong Way on One-Way Starting in Traffic Entering / Leaving Parked Position Merging / Diverging Changing Lanes Driverless Vehicle (Moving) Driverless Vehicle (Stalled) Driverless Vehicle (Stopped) U-Turn Swerving Negotiating Curve
18. Slowing / Stopping 19. Stopped 20. Waiting to Turn Left 21. Waiting to Turn Right 22. Waiting for Traffic Signal 23. Waiting for Pedestrian 24. Waiting for Vehicle To Turn 25. Waiting for Vehicle Ahead PEDESTRIAN MOVEMENT 31. Crossing at Intersection 32. Crossing Not at Intersection 33. Moving With Traffic 34. Moving Against Traffic 35. Pedestrian on Roadway 36. Stepped Into Vehicle Path 37. Not on Roadway 38. Other Action on Roadway
OTHER PROPERTY DAMAGE Estimate of total damage amount to property other than vehicle.
q
* DESCRIBE OR EXPLAIN IN NARRATIVE
q
q
q
q
q
q
q
q
q
