State of West Virginia Uniform Traffic Crash Report. Crash Data. Crash Record Number: Reporting Agency's Record Number: Page of

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1 State of West Virginia Uniform Traffic Crash Report Crash Data Crash Record Number: Reporting Agency's Record Number: Page of # of Vehicles Involved: # of n-motorists Involved: # of Fatal Injuries: # of A B or C Injuries: Date / Time of Crash: County: Highway Class: Interstate US WV County/HARP Private Road City Street / Date / Time Crash Reported: / Municipality or Place of Crash: State Park / Forest Road Private Property/Off-Roadway Supplemental Designation: Route: / Milepost: Ramp: Street: GPS Coordinates: Time of Arrival: Latitude DOH Form: 17-c t Applicable Spur rth East Truck Route Alternate Ramp South West Toll Longitude Description of Location: Intersecting Street: Relation to Junction / Junction Type: n-junction Junction, n-interchange Area Junction, Interchange Area Intersection Intersection-Related Interstate to Interstate Railroad Grade Crossing Median Crossover-Related Business or Residential Driveway/Alley Access n-interchange Thru Roadway Merge/Diverge Area Intersection Intersection-Related Entrance / Exit Ramp Part of Interchange Manner of Collision: Angle (Front to Side) Same Direction Right Angle Single Vehicle Crash Rear End Head-On Sideswipe, Same Direction OR Angle (Front to Side) Opp. Direction OR Angle - Direction Sideswipe, Opposite Direction Rear-to-Side Rear-to-Rear OR t Specified Weather (Select Up to 2): Clear Rain Blowing Snow Cloudy Sleet, Hail, or Freezing Rain Severe Crosswinds Fog, Smog, Smoke Snow Blowing Sand, Soil, Dirt Roadway Surface Condition: Dry Slush Mud, Dirt, Gravel, Sand Wet Ice / Frost Snow Water (Standing / Moving) #: Location of First Harmful Event: Lighting: Intersection Type: 4-Way Intersection T Intersection Y Intersection Intersection as Part of Interchange Traffic Circle / Roundabout 5-Point or More Environmental Contributing Circumstances (Select Up to 3): ne Weather Conditions Physical Obstruction(s) Glare Animal(s) in Roadway Type: : Daylight Dark - Lighted Dark - t Lighted Dawn Dusk On Roadway Roadside In Parking Lane or Zone Outside of Shoulder Gore Off Roadway, Right-of-Way Median Separator Location Unknown Unknown Roadway Surface Type: Asphalt Concrete Gravel Dirt Brick : First Harmful Event: COLLISION WITH: Bridge Overhead Structure Overturn / Rollover Pedestrian Bridge Pier or Support Fire / Explosion Pedalcycle Bridge Rail Immersion Railway Vehicle Culvert Jackknife Animal Curb Cargo / Equipment Loss or Shift Motor Vehicle in Transport Ditch Fell / Jumped from Motor Veh Parked Motor Vehicle Embankment Thrown or Falling Object Work Zone / Maintenance Equip Guardrail Face n-collision n-fixed Object Impact Attenuator / Crash Cushion Guardrail End Cable Median Barrier Concrete Traffic Barrier Traffic Barrier Tree (Standing) Utility Pole/Light Support Traffic Sign Support Traffic Signal Support Post, Pole, or Support Fence Mailbox Fixed Object

2 Reporting Agency's Record Number: Page of Road - Contributing Circumstances: (Select Up to 3) ne Road Surface Condition (Wet, Icy, etc.) Debris Ruts, Holes, Bumps Worn, Travel Polished Surface Obstruction in Roadway Pavement Markings t Visible Shoulders ne Low Soft High Problem w/ Traffic Control Device Inoperative Missing Obscured Work Zone Utility Construction Maintenance n-highway Work School Bus Related:, School Bus Directly Involved, School Bus Indirectly Involved School Zone Related: Type of School Zone Sign: When Present ne When Flashing Lists Specific Times School Zone Flashers: Present, t Active Present, Active t Present School Zone Speed Limit: Work Zone Related: Workers Present: Unknown Work Zone Speed Limit: Location of Crash in Work Zone: Before 1st Warning Sign Advance Warning Area Transition (Merge) Area Activity Area Termination Area Type of Work Zone: Intermittent or Lane Closure Moving Work Lane Shift / Crossover Work on Shoulder or in Median NARRATIVE: Describe What Happened. Refer to Vehicles by Number Assigned on this Form. CRASH DIAGRAM: (Draw Crash Scene - Including Roadway Layout, Vehicles, Individuals or Objects Struck, Traffic Controls, etc.) IMPORTANT: Number Vehicles According to the Numbers Assigned on this Form. Draw Arrow Pointing rth in Box Reported By: State Police Sheriff's Dept Municipal PD Photos Taken: Video Taped: By Whom: By Whom: The information contained in this report reflects my best knowledge and judgment: Investigating Officer's Name: Number: Signature: Phone: Assisting Officer's Name(s): ORI Number: Agency: Reconstructed: By Whom: Date of Submission:

3 VIN State of West Virginia Uniform Traffic Crash Report Vehicle Data Vehicle Type: Motor Veh in Transport Parked Motor Veh / Trailer Working Veh / Equipment Owner's Name(s): Make Model Model Year Body Type Color Special Function of Motor Vehicle: ne Police Courtesy Patrol Used as School Bus Ambulance Taxi Used as Bus Fire Truck Military Direction of Travel Before Crash: rthbound Eastbound t on Road Southbound Westbound Unknown Traffic Control Device Type: ne Person (Flagger, etc.) Traffic Control Signal Flashing Overhead Signal Stop Sign Yield Sign School Zone Signs Warning Signs Railroad Crossing Device Traffic Control Functioning Properly: Vehicle Maneuver / Action: Essentially Straight Ahead Backing Changing Lanes Overtaking / Passing Parked Turning Right Turning Left Displaying Hazardous Materials Placard: Occurrence of Fire: Making U-Turn Slowing Stopped in Traffic Leaving Traffic Lane Entering Traffic Lane Negotiating a Curve Fire, Vehicle Caught Fire Plate Class Applicable Speed Limit (MPH): Modified Vehicle: DOH Form: 17-veh Vehicle Number: Reporting Agency's Record Number: Page of License Plate Number Used as an Emergency Vehicle: State Roadway Description: Horizontal Alignment: Straight Curve Left Underride / Override: Two-Way, t Divided Two-Way, t Divided w/ Cont. Left Turn Lane Curve Right Reg Year Underride or Override Underride, Compartment Intrusion Underride, Compartment Intrusion Crash Avoidance Maneuver: ne Evident or Reported Braking - Skidmarks Evident Braking - Driver Stated Braking - Evidence Steering - Evidence or Stated Steering and Braking Vehicle is Primarily Used to Transport Goods, Property, or People for Commerce: Vehicle Used as a Bus: Public School Bus Private School Bus Scheduled Service Bus Hit and Run: Two-Way, Divided, Unprotected Median Two-Way, Divided, with Median Barrier One-Way Roadway Vertical Alignment:, Did t Leave Scene, Driver Left Scene, Car and Driver Left Scene Level Uphill Sag (Bottom) Hillcrest Downhill Underride, Compartment Intrusion Unknown Override, Motor Vehicle in Transport Override, Motor Vehicle Contributing Circumstances, Motor Vehicle (Select up to 2): ne Brakes Wipers Steering Power Train Mirrors Suspension Home Phone Phone Tires Wheels Lights (Head, Signal, Tail, etc.) Windows Truck Coupling/Trailer Hitch/Safety Chains Manner, in which Vehicle was Removed from Scene: Proof of Liability Insurance: t Req Ins. Co: Policy : Ins. Agent Name or Phone Total Lanes in Roadway: For Undivided Highways: Count Total Lanes in Both Directions. (Excluding Designated Turn Lanes) For Divided Highways: Count Only Lanes in Direction Vehicle was Traveling Prior to Crash. Extent of Damage Damage Minor Damage Functional Damage Disabling Damage Total / Max Occupants of Veh: Driven Towed Due to Damage Towed Due to Driver Condition Left at Scene Towed to: Registration Status: Properly Registered Improperly Registered Registration Required Commuter Bus Tour Bus Shuttle Bus Church Bus Modified for Personal/Private Use Towed by: Driver Presence at Time of Crash: Exp Date: Vehicle Impact Role: Striking Struck Veh Travel Speed (MPH): Driver Operated Vehicle Driverless Vehicle GVWR or GCWR: Number of Axles: Single Vehicle Both Less Than or Equal To 10,000lbs 10,001-26,000 lbs More Than 26,000lbs /

4 Vehicle Number: Reporting Agency's Record Number: Page of Crash Events: 01 Overturn / Rollover 02 Fire / Explosion 03 Immersion 04 Jackknife 05 Cargo/Equipment Loss or Shift 06 Equipment Failure 07 Separation of Units 08 Ran Off Road Right 09 Ran Off Road Left Select the ONE Diagram that best matches the involved vehicle and identify damaged areas: 13 Top 14 Undercarriage 10 Cross Median / Centerline 11 Downhill Runaway 12 Fell / Jumped from Motor Vehicle 13 Thrown or Falling Object 14 n-collision COLLISION WITH: 15 Pedestrian 16 Pedalcycle 17 Railroad Vehicle 18 Animal 29 Curb 30 Ditch 31 Embankment 32 Guardrail Face 33 Guardrail End 34 Cable Median Barrier 35 Concrete Barrier 36 Traffic Barrier 37 Tree (Standing) 38 Utility Pole / Light Support Using the Numbers from the Diagram Above, Identify the Following: Area of Initial Impact: Most Damaged Area: Number of Trailing Units: Trailing Unit #1: Trailing Unit #2: VIN VIN Same as Power Unit Same as Power Unit 13 Top 14 Undercarriage Plate Class Plate Class Carrier / Owner's Name: License Plate Number Carrier / Owner's Name: License Plate Number 13 Top 14 Undercarriage 19 Motor Vehicle in Transport 20 Parked Motor Vehicle 21 Struck by Falling / Shifting Cargo or Anything Set in Motion by Veh 22 Work Zone / Maintenance Equip 23 n-fixed Object 24 Impact Attenuator / Crash Cushion 25 Bridge/Overhead Structure 26 Bridge Pier or Support 27 Bridge Rail 28 Culvert Single Unit Vehicle Motorcycle ATV Pass. Veh, Towing Unit Bus Tractor Trailer 13 Top 14 Undercarriage 13 Top 14 Undercarriage State Year Make Model Model Year Body Type Phone: Phone: State Year Make Model Model Year Body Type 39 Traffic Sign Support 40 Traffic Signal Support 41 Post, Pole, or Support 42 Fence 43 Mailbox 44 Fixed Object Sequence of Events: Most Harmful Event: Property Damaged Than Vehicles: ne Work Zone / Maintenance Equipment Impact Attenuator / Crash Cushion Bridge / Tunnel Culvert Guardrail Concrete Barrier Cable Median Barrier Traffic Barrier Utility Pole / #: Light Support Traffic Sign Support Traffic Signal Support Post, Pole or Support Fence Mailbox Fixed Object Damaged Property Owner(s): WVDOH City : Damaged Property Location: On Pavement Right Side of Road Left Side of Road Private Utility Company Trailing Unit #3: Same as Power Unit Carrier / Owner's Name: Phone: VIN Plate Class License Plate Number State Year Make Model Model Year Body Type

5 Reporting Agency's Record Number: State of West Virginia Uniform Traffic Crash Report Driver Data DOH Form: 17-drv Vehicle Number (from Vehicle Data Page) Page of Driver's Name: Home Phone: Same as Veh Owner Last First Middle Suffix Phone: Driving License: License Type: t Licensed GDL Level 1 CDL Instruction Permit CDL Driving License GDL Level 2 Motorcycle Instruction Permit Instruction Permit GDL Level 3 Motorcycle Only License Restrictions: (Select All that Apply) ne Corrective Lenses Mechanical Devices Prosthetic Aid Automatic Transmission Outside Mirror Limit to Daylight Only Limit to Employment Must Be Accompanied by Adult Driver Condition at Time of Crash: Apparently rmal Emotional Ill Fell Asleep, Fainted, Fatigued Under the Influence of Medication/Alcohol/Drugs Driver Use of Alcohol Suspected: Alcohol Use Suspected: Unknown Alcohol Test Given: Limited - CDL Intrastate Only Motor Vehicles w/o Air Brakes Military Vehicles Only Except Class A Bus Except Class A and Class B Bus Except Tractor - Trailer Farm Waiver Test Given ne Given Test Refused Action(s) of Driver that Contributed to the Crash: (Select Up to 4) Issuing State: Date of Birth: ne Improper Turn Operated Veh in Ran Off Road Improper Backing Aggressive Manner Failed to Yield Right of Way Improper Passing Swerved or Avoided Disregarded Traffic Signs Wrong Side or Wrong Way Over Correcting / Ran Red Light Followed Too Closely Over Steering Disregarded Road Markings Failed to Keep in Proper Lane Improper Action Exceeded Posted Speed Limit Operated Veh in Erratic, Reckless, Drove Too Fast For Conditions or Careless Manner Type of Alcohol Test Given (Select Up to 2): Blood Serum Breath Field Class: A B C Endorsements: (Select Up to 5) Urine : Lic. Number: ne T - Double/Triple Trailers P - Passenger Vehicle S - School Bus N - Tank Vehicle H - Hazardous Materials X - Combined Tank / Haz. Materials F - Motorcycle (WV Only) - n-wv Licenses Only PBT Results: Pass Fail Status: Valid Expired Suspended Revoked Probation Surrendered Valid/Interlock Fraudulent BAC Results: Pending Unknown Driver Use of Drugs Suspected: Drug Use Suspected: Drug Test Given: Type of Drug Test Given: Drug Test Results (Check All that Apply): Unknown Test Given ne Given Test Refused Unknown if Tested Blood Serum Urine DRE ne Marijuana Cocaine Opiate Amphetamine Pending PCP Controlled Substance Drug Driver Distracted By: t Distracted Electronic Device Outside Vehicle Electronic Communication Device Inside Vehicle

6 Reporting Agency's Record Number: Known or Suspected Violation(s) by Driver: Violations Reckless/Careless/Hit and Run Type Offenses Negligent Homicide Reckless Driving; Driving to Endanger; Negligent Driving Inattentive, Careless, Improper Driving Fleeing or Eluding Law Enforcement Failure to Obey Law Enforcement, Fireman, Authorized Person Directing Traffic Hit and Run, Failure to Stop After Accident Serious Violation Resulting in Death Impairment Offenses Driving While Intoxicated (Alcohol or Drugs) or BAC Above Limit Driving While Impaired Driving Under Influence of Controlled Substance Driving Under Influence of n-controlled Substance Drinking While Operating Illegal Possession of Alcohol or Drugs Driving with Detectable Alcohol (CDL or Under 21 Years of Age) Refusal to Submit to Chemical Test Speed Related Offenses Failure to Maintain Control of Vehicle Racing Speeding (Above Speed Limit) Speed Greater than Reasonable and Prudent Exceeding Special Limit Driving too Slowly Citation(s) Issued to Driver: Charge Vehicle Number (from Vehicle Data Page) Page of Rules of the Road - Traffic Signs and Signals Failure to Stop for Red Signal Failure to Stop for Flashing Red Signal Violation of Turn on Red Failure to Obey Flashing Signal (Yellow or Red) Failure to Obey Signal, Generally Violation of RR Grade Crossing Device or Regulations Failure to Obey Stop Sign Failure to Obey Yield Sign Failure to Obey Traffic Control Device Rules of the Road - Lane Usage Unsafe or Prohibited Lane Change Improper Use of Lane Certain Traffic to Use Right Lane Lane Violations, Generally Rules of the Road - Wrong Side, Passing and Following Driving Wrong Way on One-Way Road Driving on Left, Wrong Side of Road, Generally Improper, Unsafe Passing Passing on Right (Drive Off of Pavement to Pass) Passed Stopped School Bus Failure to Give Way When Overtaken Following Too Closely Wrong Side, Passing, Following Violations, Generally Rules of the Road - Turning, Yielding, Signaling Turn in Violation of Traffic Control Improper Method and Position of Turn Failure to Signal for Turn or Stop Failure to Yield to Emergency Vehicle Failure to Yield, Generally Enter Intersection when Space Insufficient n-moving License and Registration Violations Driving While License Suspended or Revoked Driver License Restrictions Commercial Driver Violations Vehicle Registration Violations Failure to Carry Insurance Card Driving Uninsured Vehicle n-moving Violations, Generally Equipment Lamp Violations Brake Violations Failure to Require Restraint Use Motorcycle Equipment Violations Violation of Hazardous Cargo Regulations Size, Weight, Load Violations Equipment Violations, Generally Violations State Code / Municipal Ordinance Parking Theft, Unauthorized Use of Motor Vehicle Driving Where Prohibited Moving Violation Citation Number Warning STATEMENT OF DRIVER:

7 State of West Virginia Uniform Traffic Crash Report Driver and Vehicle Passenger Data DOH Form: 17-pas Crash Record Number: Reporting Agency's Record Number: Page of Name Veh Occupant Indiv # Last First Middle Int. Suffix # Type Social Security # Birthdate Age Gender Injury Seating Position Row Seat Occupant Protection Type Used Proper Use App. Helmet Occupant Type Codes: 01 Driver 02 Passenger 03 Occupant of Motor Veh t in Transport 04 Unknown Vehicle Passenger Gender: M Male F Female Indiv # from Above Airbag Trapped Extricated Ejected Injury Status Codes: K Killed O Injury Seating Position Codes: ROW SEAT 1 Front 1 Left 2 Second 2 Middle 3 Third 3 Right 4 Fourth 4 5 Row 5 Unknown 6 Unknown Ejection Path Medical Transport By A Incapacitating Injury M Medical Condition B n-incapacitating Injury n-crash Related C Possible Injury Death or Injury Responding EMS Agency ID # OTHER 1 Sleeper Section of Cab 2 Enclosed Cargo Area 3 Unenclosed Cargo Area 4 Trailing Unit 5 Riding on Motor Vehicle Exterior 6 Unknown EMS Response Run Number Type of Occupant Protection System Used Codes: Receiving Facility Name 01 ne Used 02 Shoulder and Lap Belt Used 03 Shoulder Belt Only Used 04 Lap Belt Only Used 05 Child Restraint System - Forward Facing 06 Child Restraint System - Rear Facing Proper Use of Occupant Protection: 01 Used Properly 02 Used Improperly 03 Unknown tified Time Scene Time Hospital Time 07 Booster Seat 08 Helmet Used 09 Restraint Used - Type Unknown Unable to Determine - Due to Vehicle Damage DOT Approved Helmet: Unknown Date of Death Time of Death Place of Death Airbag Deployed Codes: DEPLOYED (This Seat): 01 Front 02 Side Multiple Directions (Front and Side) 10 Unable to Determine - Due to Vehicle Damage NOT DEPLOYED (This Seat): 05 Available, Didn't Deploy 06 Available, Turned Off 07 ne Installed 08 Previously Deployed - t Replaced 09 Disabled or Removed Trapped / Extricated Codes: 01 t Trapped 02 Trapped / Extricated 03 Unknown Medically Transported By: 01 t Transported 02 EMS Ejection Codes: 01 t Ejected 02 Ejected, Partially 03 Ejected, Totally 04 Unknown 03 Law Enforcement Refused 06 Unknown Ejection Path: 01 Thru Side Door Opening 02 Thru Side Window 03 Thru Windshield 04 Thru Back Window Place of Victim's Death: 01 At Scene 02 En Route 05 Thru Back Door / 08 Path Tailgate Opening 09 Unknown Path 06 Thru Roof Opening 07 Thru Convertible (Top Up) Roof 03 At Medical Facility 04 Home 05

8 Reporting Agency's Record Number: State of West Virginia Uniform Traffic Crash Report Statement Page DOH Form: 17-st of Statement of: Involved Vehicle Passenger / Driver Involved n-motorist Uninvolved Witness Vehicle Number: Person Number: Person Number: Name: Home Phone: Last First Middle Suffix Phone: STATEMENT:

9 State of West Virginia Uniform Traffic Crash Report n-motorist Data DOH Form: 17-nm Crash Record Number: Reporting Agency's Record Number: Page of Name Person Indiv # Last First Mid. Int. Suffix Type Social Security # Birthdate Age Gender Injury Veh Number of Motor Veh Striking Action PRIOR to Crash Location PRIOR to Crash Contributing Actions #1 #2 Location at Time of Crash Person Type Codes: 05 Pedestrian 06 Pedestrian (Wheelchair, Skater, etc.) 07 Bicyclist n-motorist Action PRIOR to Crash: 01 Walking Adjacent to Roadway 02 Entering or Crossing Roadway 03 Recreational Pursuit 04 Walking To/From School n-motorist Location at Time of Crash: 01 Marked Crosswalk at Intersection 02 At Intersection, but Crosswalk 03 n-intersection Crosswalk Indiv # from Above Use of Safety Equipment #1 #2 Traffic Control Device #1 #2 Medical Transport By 08 Cyclist 09 Occupant of n-motor Veh Transportation Device 10 Unknown Type of n-motorist 05 Approaching or Leaving Veh 09 Playing 06 Pushing Motor Vehicle 10 Standing 07 Cycling 08 Working 11 Working on Vehicle Driveway Access Crosswalk 07 Island 05 In Roadway (t in Crosswalk or Intersection) 08 Shoulder 06 Median 09 Sidewalk Responding EMS Agency ID # EMS Response Run Number n-motorist Location PRIOR to Crash: 01 In Roadway 02 Adjacent to Roadway Gender: M Male F Female Receiving Facility Name Injury Status Codes: K Killed O Injury Actions of n-motorist that Contributed to the Crash (Select Up to 2): 01 ne 02 Improper Crossing 03 Darting / Running 04 In Roadway (Stand, Sit) 10 Roadside 11 Outside of Trafficway 12 Dedicated Bike Lane tified Time A Incapacitating Injury B n-incapacitating Injury C Possible Injury 05 Failure to Yield Right of Way 09 Wrong Side of Road 06 t Visible Inattentive 08 Failure to Obey Traffic Signs, Signals, or Officer 13 Shared-Use Path or Trails 14 Inside Building 15 Scene Time Hospital Time Date of Death M Medical Condition n-crash Related Death or Injury 16 Unknown Time of Death Place of Death Safety Equipment Used (Select Up to 2): 01 t Applicable 05 Reflective Clothing 02 ne Used 06 Lighting 03 Helmet Protective Pads n-motorist's Traffic Control Device (Select Up to 2): 01 Marked Crosswalk 05 ne 02 Traffic Signal with Pedestrian Signals 03 Traffic Signal with NO Pedestrian Signals 04 Crossing Guard Medically Transported By: 01 t Transported 02 EMS 03 Law Enforcement 04 Refused Unknown Place of Victim's Death: 01 At Scene 02 En Route 03 At Medical Facility 04 Home 05

10 Reporting Agency's Record Number: Page of Indiv # from Front Last Name First Condition at Time of Crash Suspected Y/N Alcohol Related Test Given Type of Test BAC Results Suspected Y/N Test Given Drug Related Type of Test Results Test n-motorist Condition at Time of Crash: 1 Apparently rmal 2 Physically Impaired 3 Emotional 4 Ill 5 Asleep, Fainted, Fatigued 6 Under the Influence of Medication/Alcohol/Drugs 7 Violation(s) Suspected of or Committed by n-motorist: 01 Violations Reckless/Careless/Hit and Run Type Offenses 02 Inattentive, Careless, Improper Driving 03 Fleeing or Eluding Law Enforcement 04 Failure to Obey Law Enforcement, Fireman, Authorized Person Directing Traffic Impairment Offenses Indiv # from Above 05 Illegal Possession of Alcohol or Drugs 06 Refusal to Submit to Chemical Test 07 Public Intoxication Violations Suspected of or Committed by n-motorist #1 #2 #3 #4 Alcohol Test Given: 01 Test Given 01 Blood 02 ne Given 03 Test Refused BAC Results: Type of Alcohol Test Given: 02 Serum 03 Breath Enter BAC Level if Available P Pending U Unknown Rules of the Road - Traffic Signs and Signals Charge 08 Failure to Stop for Red Signal 09 Failure to Stop for Flashing Red Signal 10 Violation of Turn on Red 11 Failure to Obey Flashing Signal (Yellow or Red) 12 Failure to Obey Signal, Generally 13 Violation of RR Grade Crossing Device or Regulations 14 Failure to Obey Stop Sign 15 Failure to Obey Yield Sign 16 Failure to Obey Traffic Control Device 04 Field 05 Urine 06 Drug Test Given: 01 Test Given 03 Test Refused 02 ne Given 04 Unknown if Tested Drug Test Results: 01 ne 02 Marijuana 03 Cocaine Citation(s) Issued to n-motorist State Code / Municipal Ordinance Rules of the Road - Lane Usage 17 Unsafe or Prohibited Lane Change 18 Improper Use of Lane 19 Lane Violations, Generally Rules of the Road - Turning, Yielding, Signaling 20 Turn in Violation of Traffic Control 21 Failure to Signal for Turn or Stop 22 Failure to Yield to Emergency Vehicle 23 Failure to Yield, Generally 04 Opiate 05 Amphetamine 06 PCP Citation Number Type of Drug Test Given: 01 Blood 04 DRE 02 Serum Urine 07 Controlled Substance 08 Drug 09 Pending Equipment Warning 24 Bicycle Helmet Violations 25 Equipment Violations, Generally Violations 26 Jaywalking 27 Driving Where Prohibited 28 Moving Violation

11 Reporting Agency's Record Number: Carrier Name: State of West Virginia Uniform Traffic Crash Report Commercial Motor Vehicle (CMV) Data DOH Form: 17-cmv Vehicle Number (from Vehicle Data Page) Page of Carrier US DOT Number: State ID Number: Lessee / Lessor Name: US DOT Number: State ID Number: Haz Mat Placard Number: Commercial Vehicle Configuration Passenger Veh w/ Haz Mat Placard Light Truck w/ Haz Mat Placard Bus/Large Van (Seats 9-15, Including Driver) Bus (Seats More Than 15, Including Driver) Single Unit Truck (2 Axles, 6 Tires) Carrier Classification Haz Mat Released from Cargo Compartment: Unknown Interstate Intrastate Government Veh - t in Commerce Veh - t in Commerce Carrier Information Source: Shipping Papers Single Unit Truck Pulling a Trailer Truck Tractor (Bobtail) Log Book Lease Driver Vehicle Reg Vehicle Side Did Crash Occur on a Coal Resource Transportation System (CRTS) Route? Truck Tractor w/ Semi-Trailer : Unknown Single Unit Truck (3 or More Axles) Truck Tractor w/ Double Truck Tractor w/ Triple Piggy Back Truck - Can't Classify

12 Reporting Agency's Record Number: Vehicle Number (from Vehicle Data Page) Page of Commercial Cargo Body Type: t Applicable Bus (Seats for 9-15, Including Driver) Garbage / Refuse Bus (Seats for More Than 15, Including Driver) Grain, Chips, Gravel Van / Enclosed Box Pole Cargo Tank Flatbed Dump Concrete Mixer Auto Transporter Gross Vehicle Weight Rating (GVWR) of Power Unit: Log Intermodal Chassis Vehicle Towing Motor Vehicle Cargo Body Gross Combination Weight Rating (GCWR) - All Units: Last Known Commodity: Cargo Compartment Empty or Full at Time of Crash: Empty Full # of Passengers in CMV: Passengers Traveling with Written Permission of Carrier: CMV Self Insured: Proof of Self Insurance:

13 Crash Record Number Reporting Agency's Record Number: CRASH DIAGRAM: State of West Virginia Uniform Traffic Crash Report Diagram (Draw Crash Scene - Including Roadway Layout, Vehicles, Individuals or Objects Struck, Traffic Controls, etc.) IMPORTANT: Number Vehicles According to the Numbers Assigned on this Form. DOH Form: 17-dgrm Page of Draw Arrow Pointing rth in Box