Commonwealth of Virginia Department of Motor Vehicles Police Crash Report

Transcription

1 Crash Day of Week MILITARY Time ( hr clock) County of Crash Official DMV Use GPS Lat. GPS Long. FR00P (Rev /0) City of City or Town Name Landmarks at Scene Location of Crash (route/street) Railroad Crossing ID no. (if within 0 ft.) Local Case Number N S E W Location of Crash (route/street) Mile Marker Number Number of Vehicles At Intersection With or Miles Feet of DRIVER Driver Fled Scene Driver s Name (Last, First, Middle) Gender DRIVER Driver s Name (Last, First, Middle) Driver Fled Scene Gender Birth Drivers License Number State DL CDL Safety. Used Air Bag Ejected of Death Injury Type EMS Transport Summons Offenses Charged to Driver Issued As Result of Crash VEHICLE Vehicle Owner s Name (Last, First, Middle) Codes POSITION IN/ON VEHICLE. Driver -. Passengers. Cargo Area. Riding/Hanging On Outside -. All Other Passengers Same as Driver Vehicle Year Vehicle Make Vehicle Model Disabled CMV Towed Vehicle Plate Number State Approximate Repair Cost VIN Name of Insurance Company (not agent) SAFETY EQUIPMENT USED. Lap Belt Only. Shoulder Belt Only. Lap and Shoulder Belt. Child Restraint. Helmet. Other. Booster Seat. No Restraint Used. Not Applicable Oversize Cargo Spill Override Underride Speed Before Crash Speed Limit Maximum Safe Speed ALL Passengers Age Count Under Over - - Birth Drivers License Number State DL CDL Safety. Used Air Bag Ejected of Death Injury Type EMS Transport Summons Offenses Charged to Driver Issued As Result of Crash VEHICLE Vehicle Owner s Name (Last, First, Middle) Same as Driver Vehicle Year Vehicle Make Vehicle Model Disabled CMV Towed Vehicle Plate Number State Approximate Repair Cost VIN Name of Insurance Company (not agent) Oversize Cargo Spill Override Underride Speed Before Crash Speed Limit Maximum Safe Speed ALL Passengers Age Count Under Over - - Name of (Last, First, Middle) Name of (Last, First, Middle) EMS Transport of Death EMS Transport of Death Vehicle Used Name of (Last, First, Middle) EMS Transport of Death Name of (Last, First, Middle) EMS Transport of Death Name of (Last, First, Middle) EMS Transport of Death Name of (Last, First, Middle) EMS Transport of Death AIRBAG. Deployed Front t Deployed. Unavailable/Not Applicable. Keyed Off. Unknown. Deployed Side. Deployed Other (Knee, Air Belt, etc.). Deployed Combination EJECTED FROM VEHICLE. Not Ejected. Partially Ejected. Totally Ejected SUMMONS ISSUED AS A RESULT OF. Pending INJURY TYPE. Dead Before Report Made. Visible Signs of Injury, as Bleeding Wound or Distorted Member or Had to be Carried From Scene.. Other Visible Injury, as Bruises, Abrasions, Swelling, Limping, etc.. No Visible Injury, But Complaint of Pain, or Momentary Unconsciousness.. No Injury (driver only) Investigating Officer Badge/Code Number Agency/Department Name and Code Reviewing Officer Report File

2 DRIVER INFORMATION Crash MILITARY Time ( hr clock) County of Crash City of Local Case Number VEHICLE INFORMATION Veh Veh Veh Veh Veh Veh Veh Veh FR00P (Rev /0) Driver s Action P. No Improper Action. Exceeded Speed Limit. Exceeded Safe Speed But Not Speed Limit. Overtaking On Hill. Overtaking On Curve. Overtaking at Intersection. Improper Passing of School Bus. Cutting In Improper Passing 0. Wrong Side of Road Not Overtaking. Did Not Have Right-of-Way. Following Too Close. Fail to Signal or Improper Signal. Improper Turn Wide Right Turn. Improper Turn Cut Corner on Left Turn. Improper Turn From Wrong Lane. Other Improper Turn. Improper Backing. Improper Start From Parked Position 0. Disregarded Officer or Flagger. Disregarded Traffic Signal. Disregarded Stop or Yield Sign. Driver Distraction. Fail to Stop at Through High way No Sign. Drive Through Work Zone. Fail to Set Out Flares or Flags. Fail to Dim Headlights. Driving Without Lights. Improper Parking Location 0. Avoiding Pedestrian. Avoiding Other Vehicle. Avoiding Animal. Crowded Off Highway. Hit and Run. Car Ran Away No Driver. Blinded by Headlights. Other. Avoiding Object in Roadway. Eluding Police 0. Fail to Maintain Proper Control. Improper Passing. Improper or Unsafe Lane Change. Over Correction Condition of Driver P Contributing to the Crash. Eyesight Defective. Hearing Defective. Other Body Defects. Illness. Fatigued. Apparently Asleep. Other. Unknown Driver Vision Obscured P Vehicle Maneuver. Not Obscured. Rain, Snow, etc. on Windshield. Windshield Otherwise Obscured. Vision Obscured by Load on Vehicle. Trees, Crops, etc.. Building. Embankment. Sign or Signboard. Hillcrest 0. Parked Vehicle(s). Moving Vehicle(s). Sun or Headlight Glare. Other. Blind Spot. Smoke/Dust. Stopped Vehicle(s) Type of Driver Distractions. Looking at Roadside Incident. Driver Fatigue. Looking at Scenery. Passenger(s). Radio/CD, etc.. Cell Phone. Eyes Not on Road. Daydreaming. Eating/Drinking 0. Adjusting Vehicle Controls. Other. Navigation Device Drinking. Had Not Been Drinking. Drinking Obviously Drunk. Drinking Ability Impaired P P. Drinking Ability Not Impaired. Drinking Not Known Whether Impaired. Unknown Method of Alcohol P Determination (by police). Blood. Breath. Refused. No Test Drug Use. Unknown P. Going Straight Ahead. Making Right Turn. Making Left Turn. Making U-Turn. Slowing or Stopping. Merging Into Traffic Lane. Starting From Parked Position. Stopped in Traffic Lane. Ran Off Road Right 0. Ran Off Road Left. Parked. Backing. Passing. Changing Lanes. Other V. Entering Street From Parking Lot Skidding Tire/Mark. Before Application of Brakes. After Application of Brakes V. Before and After Application of Brakes. No Visible Skid Mark/Tire Mark Vehicle Body Type. Passenger car V. Truck Pick-up/Passenger Truck. Van. Truck Single Unit Truck (-Axles). Motor Home, Recreational Vehicle. Special Vehicle Oversized Vehicle/Earthmover/Road ment. Bicycle 0. Moped. Motorcycle. Emergency Vehicle (Regardless of Vehicle Type). Bus School Bus. Bus City Transit Bus/Privately Owned Church Bus. Bus Commercial Bus. Other (Scooter, Go-cart, Hearse, Bookmobile, Golf Cart, etc.. Special Vehicle Farm Machinery. Special Vehicle ATV. Special Vehicle Low-Speed Vehicle. Truck Sport Utility Vehicle (SUV). Truck Single Unit Truck ( Axles or More). Truck Truck Tractor (Bobtail-No Trailer) Vehicle Damage V. Unknown damage. Overturned. Motor. Undercarriage. Totaled. Fire. Other Vehicle Condition V. Lights Defective. Brakes Defective. Steering Defective. Puncture/Blowout. Worn or Slick Tires. Motor Trouble. Chains In Use 0. Vehicle Altered. Mirrors Defective. Power Train Defective. Suspension Defective. Windows/Windshield Defective. Wipers Defective. Wheels Defective. Exhaust System Special Function V Motor Vehicle. No Special Function. Taxi. School Bus (Public or Private). Transit Bus. Intercity Bus. Charter Bus. Other Bus. Military. Police 0. Ambulance. Fire Truck. Tow Truck. Maintenance. Unknown EMV in service V Truck Cover V

3 Crash MILITARY Time ( hr clock) County of Crash City of Local Case Number FR00P (Rev /0) INFORMATION Location of First Harmful C Event In Relation to Roadway. On Roadway. Shoulder. Median. Roadside. Gore. Separator. In Parking Lane or Zone. Off Roadway, Location Unknown. Outside Right-of-Way Weather Condition C. No Adverse Condition (Clear/Cloudy). Fog. Mist. Rain. Snow. Sleet/Hail. Smoke/Dust 0. Blowing Sand, Soil, Dirt, or Snow. Severe Crosswinds Light Conditions C. Dawn. Daylight. Dusk. Darkness Road Lighted. Darkness Road Not Lighted. Darkness Unknown Road Lighting. Unknown Traffic Control C Device Working. Yes Working and Obscured. Yes Not Working. Yes Not Working and Obscured. Yes Missing. No Traffic Control Device Present Traffic Control Type C. No Traffic Control. Officer or Flagger. Traffic Signal. Stop Sign. Slow or Warning Sign. Traffic Lanes Marked. No Passing Lines. Yield Sign. One Way Road or Street 0. Railroad Crossing With Markings and Signs. Railroad Crossing With Signals. Railroad Crossing With Gate and Signals. Other. Pedestrian Crosswalk. Reduced Speed School Zone. Reduced Speed Work Zone. Highway Safety Corridor Roadway Alignment. Straight Level. Curve Level. Grade Straight. Grade Curve. Hillcrest Straight. Hillcrest Curve. Dip Straight. Dip Curve 0. On/Off Ramp Roadway Surface Condition. Dry. Wet. Snowy. Icy. Muddy. Oil/Other Fluids. Other. Natural Debris. Water (Standing, Moving) 0. Slush. Sand, Dirt, Gravel Roadway Surface Type. Concrete. Blacktop, Asphalt, Bituminous. Brick or Block. Slag, Gravel, Stone. Dirt. Other C C C Roadway Description C. Two-Way, Not Divided. Two-Way, Divided, Unprotected Median. Two-Way, Divided, Positive Median Barrier. One-Way, Not Divided. Unknown Roadway Defects. Holes, Ruts, Bumps. Soft or Low Shoulder. Under Repair. Loose Material. Restricted Width. Slick Pavement. Roadway Obstructed 0. Edge Pavement Drop Off Relation to Roadway Interchange Area: C0 C. Main-Line Roadway. Acceleration/Deceleration Lanes. Gore Area (Between Ramp and Highway Edgelines). Collector/Distributor Road. On Entrance/Exit Ramp. Intersection at end of Ramp. Other location not listed above within an interchange area (median, shoulder and roadside) Intersection Area:. Non-Intersection. Within Intersection 0. Intersection-Related - Within 0. Intersection-Related - Outside 0 Other Location:. Crossover Related. Driveway, Alley-Access - Related. Railway Grade Crossing. Other Crossing (Crossings for Bikes, School, etc.) Intersection Type C. Not at Intersection. Two Approaches. Three Approaches. Four Approaches. Five-Point, or more. Roundabout Work Zone C Work Zone C Workers Present. With Law Enforcement. With No Law Enforcement. No Workers Present Work Zone Location C. Advance Warning Area. Transition Area. Activity Area. Termination Area Work Zone Type C. Lane Closure. Lane Shift/Crossover. Work on Shoulder or Median. Intermittent or Moving Work. Other School Zone C. Yes - With School Activity. No Type of Collision C. Rear End. Angle. Head On. Sideswipe Same Direction. Sideswipe Opposite Direction. Fixed Object in Road. Train. Non-Collision. Fixed Object Off Road 0. Deer. Other Animal. Pedestrian. Bicyclist. Motorcyclist. Backed Into. Other

4 Crash MILITARY Time ( hr clock) County of Crash City of Local Case Number FR00P (Rev /0) DIAGRAM DAMAGE TO PROPERTY OTHER THAN VEHICLES Approx. Repair Cost Object Struck (Tree, Fence, etc.) Property Owners Name (Last, First, Middle) VDOT Property DESCRIPTION Indicate North by Arrow 0 Yes No EVENTS Vehicle # First Event Second Event Third Event Fourth Event Most Harmful Event Vehicle # First Event Second Event Third Event Fourth Event Most Harmful Event Vehicle # First Event Second Event Third Event Fourth Event Most Harmful Event Vehicle # First Event Second Event Third Event Fourth Event Most Harmful Event First Harmful Event of Entire Crash that Results in First Injury or Damage. COLLISION WITH FIXED OBJECT. Bank Or Ledge 0. Other. Trees. Jersey Wall. Utility Pole. Building/Structure. Fence Or Post. Curb. Guard Rail. Ditch. Parked Vehicle. Other Fixed Object. Tunnel, Bridge, Underpass,. Other Traffic Barrier Culvert, etc.. Traffic Sign Support. Sign, Traffic Signal. Mailbox. Impact Cushioning Device COLLISION WITH PERSON, MOTOR VEHICLE OR NON-FIXED OBJECT. Pedestrian 0. Motor Vehicle In Transport. Train. Bicycle. Animal. Work Zone Maintenance ment. Other Movable Object. Unknown Movable Object. Other NON-COLLISION. Ran Off Road. Jack Knife 0. Overturn (Rollover). Downhill Runaway. Cargo Loss or Shift. Explosion or Fire. Separation of Units. Cross Median. Cross Centerline. ment Failure (Tire, etc). Immersion. Fell/Jumped From Vehicle 0. Thrown or Falling Object. Non-Collision Unknown. Other Non-Collision

5 Crash MILITARY Time ( hr clock) County of Crash City of Local Case Number FR00P (Rev /0) A Truck or Truck Combination Rating Greater Than 0,000 lbs. (GVWR/GCWR) COMMERCIAL MOTOR VEHICLE SECTION This form is being completed because the vehicle is: Any Motor Vehicle That Seats or More People, Including the Driver A Vehicle of Any Type with a Hazardous Materials Placard Regardless of Weight A fatality: any person(s) killed in or outside of any vehicle (truck, bus, car, etc.) involved in the crash or who dies within 0 days of the crash as a result of an injury sustained in the crash OR AND The crash resulted in: An injury: any person(s) injured as a result of the crash who immediately receives medical treatment away from the crash scene OR A tow-away: any motor vehicle (truck, bus, car, etc.) disabled as a result of the crash and transported away from the scene by a tow truck or other vehicle Vehicle Configuration Carrier Identification Commercial Motor Carrier Name Address (P.O. Box if No Street Address) Carrier s ID Number State (Intrastate Only) City State Zip V0. Passenger Car (Only if Vehicle Has Hazardous Materials Placard). Light Truck (Only if Vehicle Has Hazardous Materials Placard). Bus (Seats - People, Including Driver). Bus (Seats for People or More, Including Driver). Single Unit Truck ( Axles, Tires). Single Unit Truck ( or More Axles). Truck Trailer(s) [Single-Unit Truck Pulling Trailer(s)]. Truck Tractor (Bobtail). Tractor/Semi-trailer (One Trailer) 0. Tractor/Doubles (Two Trailers). Other Truck Greater Than 0,000 lbs. (Not Listed Above) Hazardous Material Hazardous Material Placard: Cargo Body Type. Bus (Seats - People, Including Driver). Bus (Seats For People or More, Including Driver). Van/Enclosed Box. Cargo Tank. Flatbed. Dump. Concrete Mixer. Auto Transporter. Garbage/Refuse 0. Grain/Chips/Gravel. Pole-Trailer. Vehicle Towing Another Motor Vehicle. Intermodel Container Chassis. Logging. Other Cargo Body (Not Listed Above). Not Applicable/ No Cargo Body HM Digit HM Placard Name HM Class US DOT# Vehicle Configuration V0. Passenger Car (Only if Vehicle Has Hazardous Materials Placard). Light Truck (Only if Vehicle Has Hazardous Materials Placard). Bus (Seats - People, Including Driver). Bus (Seats for People or More, Including Driver). Single Unit Truck ( Axles, Tires). Single Unit Truck ( or More Axles). Truck Trailer(s) [Single-Unit Truck Pulling Trailer(s)]. Truck Tractor (Bobtail). Tractor/Semi-trailer (One Trailer) 0. Tractor/Doubles (Two Trailers). Other Truck Greater Than 0,000 lbs. (Not Listed Above) Hazardous Material Hazardous Material Placard: HM Digit HM Placard Name HM Class V License Class Class A Class B Class C P Class DRL (regular drivers license) Class M GVWR/ GCWR Cargo Body Type. Bus (Seats - People, Including Driver). Bus (Seats For People or More, Including Driver). Van/Enclosed Box. Cargo Tank. Flatbed. Dump. Concrete Mixer. Auto Transporter. Garbage/Refuse V 0. Grain/Chips/Gravel. Pole-Trailer. Vehicle Towing Another Motor Vehicle. Intermodel Container Chassis. Logging. Other Cargo Body (Not Listed Above). Not Applicable/ No Cargo Body V Commercial Endorsement T Double Trailer P Passenger Vehicle N Tank Vehicle H Required To Be Placarded for Hazardous Materials X Combined Tank/HAZMAT O Other. 0,000 lbs. or Less. 0,00,000 lbs.. Greater Than,000 lbs. HM Cargo Present HM Cargo Released Commercial/Non-Commercial P V. Interstate Carrier. Intrastate Carrier. Not in Commerce-Government (Trucks and Buses). Not in Commerce-Other Truck (Over 0,000 lbs.) License Class Class A Class B Class C GVWR/ GCWR P Class DRL (regular drivers license) Class M V Commercial Endorsement T Double Trailer P Passenger Vehicle N Tank Vehicle H Required To Be Placarded for Hazardous Materials X Combined Tank/HAZMAT O Other. 0,000 lbs. or Less. 0,00,000 lbs.. Greater Than,000 lbs. HM Cargo Present HM Cargo Released P Carrier Identification Commercial Motor Carrier Name Address (P.O. Box if No Street Address) Carrier s ID Number State (Intrastate Only) City State Zip US DOT# Commercial/Non-Commercial V. Interstate Carrier. Intrastate Carrier. Not in Commerce-Government (Trucks and Buses). Not in Commerce-Other Truck (Over 0,000 lbs.)

6 Crash MILITARY Time ( hr clock) County of Crash City of Local Case Number FR00P (Rev /0) PEDESTRIAN # Name of (Last, First, Middle) PEDESTRIAN # Name of (Last, First, Middle) Driver s License # State Driver s License # State Gender EMS Transport Injury Type Birthdate of Death Gender EMS Transport Injury Type Birthdate of Death Pedestrian Actions P0 Pedestrian Drinking P Method of P Alcohol Determination by Police. Crossing At Intersection With Signal. Crossing At Intersection Against Signal. Crossing At Intersection No Signal. Crossing At Intersection Diagonally. Crossing Not At Intersection Rural. Crossing Not At Intersection Urban. Coming From Behind Parked Cars. Getting Off Or On School Bus. Playing In Roadway 0. Getting Off Or On Another Vehicle. Hitching On Vehicle. Walking In Roadway With Traffic Sidewalks Available. Walking In Roadway With Traffic Sidewalks Not Available. Walking In Roadway Against Traffic Sidewalks Available. Walking In Roadway Against Traffic Side Walks Not Available. Working In Roadway. Standing In Roadway. Lying In Roadway. Not In Roadway 0. Other Name of (Last, First, Middle) Name of (Last, First, Middle) EMS Transport of Death EMS Transport of Death Name of (Last, First, Middle) EMS Transport of Death Name of (Last, First, Middle) EMS Transport of Death Name of (Last, First, Middle) EMS Transport of Death Name of (Last, First, Middle) EMS Transport of Death. Had Not Been Drinking. Drinking-Obviously Drunk. Drinking-Ability Impaired. Drinking-Ability Not Impaired. Drinking-Not Known Whether Impaired Condition of Pedestrian Contributing to the Crash. Eyesight Defective. Hearing Defective. Other Body Defects. Illness. Fatigued. Apparently Asleep. Other P Use sections below for additional passengers.. Blood. Breath. Refused. No Test Pedestrian Drug Use P. Unknown Pedestrian Wear Reflective Clothing P Codes POSITION IN/ON VEHICLE. Driver -. Passengers. Cargo Area. Riding/Hanging On Outside -. All Other Passengers SAFETY EQUIPMENT USED. Lap Belt Only. Shoulder Belt Only. Lap and Shoulder Belt. Child Restraint. Helmet. Other. Booster Seat. No Restraint Used. Not Applicable AIRBAG. Deployed Front t Deployed. Unavailable/Not Applicable. Keyed Off. Unknown. Deployed Side. Deployed Other (Knee, Air Belt, etc.). Deployed Combination EJECTED FROM VEHICLE. Not Ejected. Partially Ejected. Totally Ejected SUMMONS ISSUED AS A RESULT OF. Pending INJURY TYPE. Dead Before Report Made. Visible Signs of Injury, as Bleeding Wound or Distorted Member or Had to be Carried From Scene.. Other Visible Injury, as Bruises, Abrasions, Swelling, Limping, etc.. No Visible Injury, But Complaint of Pain, or Momentary Unconsciousness.