STATE OF NEVADA TRAFFIC ACCIDENT REPORT SCENE INFORMATION SHEET Revised 1/14/04

Transcription

1 Code Revision: 1) Urban 1) Emergency Use ) Rural ) Office Report SCENE INFORMATION SHEET 1) Preliminary Report 3) Resubmission 1) Hit and Run ) Initial Report 4) Supplement Report ) Private Property 1) Property ) 3) Fatal Collision Date Time Day Beat / Sector 1) County ) City Surface Intersection Paddle Markers Reno 1) Asphalt 1) Four Way 1) None ) Concrete ) > Four Way ) Left Side Mile Marker # Vehicles # Non Motorists # s # Fatalities # Injured # Restrained 3) T 3) Right Side 3) Gravel 4) Y 4) Both Sides 5 0 4) Dirt 5) Roundabout Occurred On: (Highway # or Street Name) 1) Parking Lot HWY 395 Access Control 1) None 1) At Intersection With: Of (Cross Street) ) Full ) Or 3) Feet 4) Miles 5) Approximate 1.6 Moya Blvd 3) Partial Roadway Character Roadway Conditions Total Thru Lanes Average Roadway Widths Roadway Grade 1) Curve & Grade 1) Dry 7) Slush Main Road Travel Lane 1 Ft Relative To ) Curve & Hillcrest ) Icy 8) Standing Water 1) One 1) Not Determined 3) Curve & Level 3) Wet 9) Moving Water ) Two Storage / Turn Lane Ft 4) Straight & Grade 3) Three ) Relativety Level 4) Snow 10) Unknown 5) Straight & Hillcrest 4) Four Median Ft Roadway 0 5) Sand / Mud / Oil / Dirt / Gravel Grade 5) Five 3) Up Slope (+) 6) Straight & Level Paved Shoulder 6) > 5 7) Unknown Inside Outside 4) Down Slope (-) % 8) Other Total All Lanes: Pavement Markings and Type Highway Description Weather Conditions 1) Centerline, Broken Yellow 6) No Passing, Either Direction 1) None 1) Two-Way, Not Divided 1) Clear 7) Fog, Smog, Smoke, Ash ) Centerline, Solid Yellow 7) Turn Arrow Symbols 1 ) Two-Way, Divided, Unpro, Median ) Cloudy 8) Severe Crosswinds 3) Centerline, Double Yellow 8) Center Turn Lane Line 3) Two-Way, Divided, Median Barrier 3) Snow 9) Sleet / Hail 1 4) Lane Line, Broken White 9) Edge Line, Left, Yellow 4) One-Way, Not Divided 4) Rain 10) Unknown 1 5) Lane Line, Solid White 10) Edge Line, Right, White 5) Blowing Sand, Dirt, Soil, Snow 11) Other 6) Off Road Light Conditions Vehicle Collision Type Location of First Event 1) Dusk 6) Dark - No Roadway Lighting 1) Head On 5) Rear to Rear 1) Travel Lane 6) Outside Shoulder 11) Ramp ) Dawn 7) Dark - Spot Roadway Lighting ) Rear End 6) Sideswipe - Meeting ) Turn Lane 7) Intersection 1) Unknown 3) Daylight 8) Dark - Continuous Roadway Lighting 3) Backing 7) Sideswipe - Overtaking 3) Gore 8) Private Property 4) Unknown 9) Dark - Unknown Roadway Lighting 4) Angle 8) Non - Collision 4) Median 9) Roadside 9) Unknown 5) Inside Shoulder 10) Other Highway / Environment Factors 1) None 7) Shoulders 11) Ruts, Holes, Bumps ) Weather 8) Road Obstruction 1) Active Work Zone 13) Inactive Work Zone 3) Debris 9) Worn Traffic Surfaces 14) Animal In Roadway 4) Glare 10) Wet, Icy, Snow, Slush 1 Highway Environmental Property Damage To Other Than Vehicle Describe Property Damage Owner's Name: Owner's Address: (Street Address, City, State, Zip) First Harmful Event 1) Owner Notified Code #: 308 Description: Veh collided with median Description of Accident / Narrative Veh1 was traveling East bound on the highway when a deer began to cross the roadway. Veh1 began slowing so avoid hitting the deer. Veh was following too closely to Veh and was approximately 15MPH over the speed limit. Veh couldnt stop in time and rear ended Veh1 pushing Veh1 into the middle of the road and itself into the center median. 1) Continued On Back of Scene Information Sheet Investigation Complete Photos Taken Scene Diagram Statements Date Notified Time Notified Arrival Date Arrival Time 1) Yes ) No 1) Yes ) No 1) Yes ) No 1) Yes ) No # Investigator(s) ID Number Date Reviewed By Date Reviewed Penny Cotter c Larry Hill of 6 Scene Information

2 SCENE INFORMATION SHEET Description of Accident / Narrative Continuation A.I.C.: Scene Information of 6

3 Vehicle # # s 1) At Fault 1 ) Non Contact Vehicle Direction 1) North 3) East of Travel: ) South 4) West Vehicle Action: 1) Straight ) Backing 3) Left Turn 4) Right Turn 5) U-Turn 6) Parked Highway / Street Name: 7) Wrong Way 8) Stopped (^) 9) Passing 10) Racing 11) Leaving Parked 1) Entering Lane 13) Leaving Lane 14) Other Turning HWY ) Enter Parked (#) 16) Driverless Vehicle 17) Lane Change 18) Other Travel Lane #: Driver: (Last Name, First Name, Middle Name Suffix) Grant Dennis Edward 8478 York Ave 1 01 Restraints: O Location: 0 OLN: Class: 1) CDL License Status: s: ) DL NV Compliance: Endorsements Restrictions Driver Factors 1) Restrict ) Endorse 1) Apparently Normal P F ) Driver ill / Injured Alcohol/Drug Involvement ) Had Been Drinking 7) Other Improper Driving 1) Not Involved Method of Determination (check up to ) Test Results: 3) Drug Involvement 8) Driver Inattention / Distracted ) Suspected Impairment 1) Field Sobriety Test 4) Urine Test 4) Apparently Fatigued / Asleep 9) Physical Impairment 3) Alcohol 4) Drugs ) Evidentiary Breath 5) Blood Test 3) Driver Admission 6) Preliminary Breath Test 5) Obstructed View 10) Unknown Vehicle Year: Vehicle Make: Vehicle Model: Vehicle 0 0 F o r d Mustang D Vehicle Factors Plate / Permit No.: Expiration Date: Vehicle Color: 1) Failed To Yield Right Of Way 9) Failed To Maintain Lane 16) Driverless Vehicle 8367HM NV Grey ) Disregard Control Device 10) Following Too Close 17) Unsafe Backing Vehicle Identification Number: 3) Too Fast For Conditions 11) Unsafe Lane Change 18) Ran Off Road ) Exceeding Speed Limit 1) Made Improper Turn 19) Hit and Run Registered Owner Name: 5) Wrong Way / Direction 13) Over Correct/Steering 0) Road Defect (^) 1) Same As Driver Grant Dennis Edward 6) Mechanical Defects 14) Other Improper Driving 1) Object Avoidance Registered Owner Address: 7) Drove Left Of Center 15) Aggressive / Reckless / Careless 8478 York Ave 8) Other ) Unknown (#) Insurance Company Name: 1st Contact Damaged Areas 1) Insured State Farm 3 4 1) Front Policy Number: Effective: To: ) Right Side K ) Left Side Insurance Company Address or 1 5 4) Rear 838 Prater Way ) Right Front 6) Right Rear Towed By: 1) Vehicle Towed 7) Top Removed To: 8) Under Carriage 1) Over Ride ) Under Ride 9) Left Front Distance Traveled Speed Estimate Extent Of Damage 10) Left Rear 1) Speed Zone 11) Stop Sign After Impact From To Limit 1) Minor 4) Total 11) Unknown ) Signal Light 1) Yield Sign 75 feet ) Moderate 5) None 1) Other 3) Major 6) Unknown 3) Flashing Light 13) R. R. Sign Sequence Of Events 4) School Zone 14) R. R. Gates Code # Description Collision With Most Harmful 5) Ped. Signal 15) R. R. Signal (#) Fixed Object Event 6) No Passing F 16) Marked Lanes 1st 07 Deer 7) No Controls 17) Tire Chains/Snow Req. nd 17 Slow / Stopped Vehicle 8) Warning Sign 18) Permissive Green 3rd 14 Motor Vehicle in Transport (Moving Vehicle) 9) Turn Signal 4th 316 Embankment 10) Other 5th 1) NRS ) CFR 3) CC / MC 4) Pending (1) 1) NRS ) CFR 3) CC / MC () Investigator(s) ID Number Date Reviewed By Date Reviewed Penny Cotter c Larry Hill of 6 VEHICLE INFORMATION

4 Name: (Last Name, First Name, Middle Name Suffix) Whalen Tonya Allison 4347 Whitewood Dr Reno NV Restraints: 07 O Location: 0 s: Name: (Last Name, First Name, Middle Name Suffix) Restraints: Location: s: Name: (Last Name, First Name, Middle Name Suffix) Restraints: Location: s: 1) Trailing Unit 1 1) Trailing Unit 1) Trailing Unit 3 Commercial Vehicle Configuration 1) Commercial Vehicle ) School Bus 1) Bus, 9-15 s 6) Tractor Only 11) Tractor / Semi Trailer Source ) Bus, > 15 s 3) Single Axle and 6 Tire 4) Single > 3 Axle 5) Any 4 Tire Vehicle 7) Tractor / Trailer 8) Tractor / Doubles 9) Tractor / Triples 10) Truck with Trailer 1) Passenger Vehicle, (Haz-Mat) 13) Light Truck, (Haz-Mat) 14) Other Heavy Vehicle 1) Driver ) Log Book 3) Shipping Papers / Trip Manifest 4) State Reg. 5) Side Of Vehicle Carrier Name: Carrier Power Unit GVWR 1) < 10,000 Lbs ) 10,000-6,000 Lbs 3) > 6,000 Lbs City Zip: 1) Haz-Mat ) Released Cargo Body Type Haz-Mat ID #: Type of Carrier NAS Safety Report #: 1) Pole ) Tank 3) Flatbed 6) Van / Box 7) Concrete Mixer 8) Auto Carrier 11) Grain, Gravel Chips 1) Bus, 9-15 s 13) Bus, > 15 s Hazard Classification #: 1) Single State ) USDOT 3) Canada Carrier Number: 4) Dump 9) Garbage/Refuse 14) Other 10) Not Applicable Vehicle Information 4) Mexico 5) None 4 of 6

5 Vehicle # # s 1) At Fault 3 ) Non Contact Vehicle Direction 1) North 3) East of Travel: ) South 4) West Vehicle Action: 1) Straight ) Backing 3) Left Turn 4) Right Turn 5) U-Turn 6) Parked Highway / Street Name: 7) Wrong Way 8) Stopped (^) 9) Passing 10) Racing 11) Leaving Parked 1) Entering Lane 13) Leaving Lane 14) Other Turning HWY ) Enter Parked (#) 16) Driverless Vehicle 17) Lane Change 18) Other Travel Lane #: Driver: (Last Name, First Name, Middle Name Suffix) Moore Michelle Lee Greg Street 1 01 Restraints: O Location: 0 OLN: Class: 1) CDL License Status: s: ) DL NV Compliance: Endorsements Restrictions Driver Factors 1) Restrict ) Endorse 1) Apparently Normal 6) Driver ill / Injured Alcohol/Drug Involvement ) Had Been Drinking 7) Other Improper Driving 1) Not Involved Method of Determination (check up to ) Test Results: 3) Drug Involvement 8) Driver Inattention / Distracted ) Suspected Impairment 1) Field Sobriety Test 4) Urine Test 4) Apparently Fatigued / Asleep 9) Physical Impairment 3) Alcohol 4) Drugs ) Evidentiary Breath 5) Blood Test 3) Driver Admission 6) Preliminary Breath Test 5) Obstructed View 10) Unknown Vehicle Year: Vehicle Make: Vehicle Model: Vehicle H o n d Civic 4 D Vehicle Factors Plate / Permit No.: Expiration Date: Vehicle Color: 1) Failed To Yield Right Of Way 9) Failed To Maintain Lane 16) Driverless Vehicle 3483TG NV Green ) Disregard Control Device 10) Following Too Close 17) Unsafe Backing Vehicle Identification Number: 3) Too Fast For Conditions 11) Unsafe Lane Change 18) Ran Off Road ) Exceeding Speed Limit 1) Made Improper Turn 19) Hit and Run Registered Owner Name: 5) Wrong Way / Direction 13) Over Correct/Steering 0) Road Defect (^) 1) Same As Driver Moore Michelle Lee 6) Mechanical Defects 14) Other Improper Driving 1) Object Avoidance Registered Owner Address: 7) Drove Left Of Center 15) Aggressive / Reckless / Careless Greg Street 8) Other ) Unknown (#) Insurance Company Name: 1st Contact Damaged Areas 1) Insured All State 3 4 1) Front Policy Number: Effective: To: ) Right Side 8373-Y ) Left Side Insurance Company Address or 1 5 4) Rear 716 Carville Dr ) Right Front 6) Right Rear Towed By: 1) Vehicle Towed Mikes Auto Towing 7) Top Removed To: 8) Under Carriage Buzz's Auto Body 1) Over Ride ) Under Ride 9) Left Front Distance Traveled Speed Estimate Extent Of Damage 10) Left Rear 1) Speed Zone 11) Stop Sign After Impact From To Limit 1) Minor 4) Total 11) Unknown ) Signal Light 1) Yield Sign 50 Feet ) Moderate 5) None 1) Other 3) Major 6) Unknown 3) Flashing Light 13) R. R. Sign Sequence Of Events 4) School Zone 14) R. R. Gates Code # Description Collision With Most Harmful 5) Ped. Signal 15) R. R. Signal (#) Fixed Object Event 6) No Passing F 16) Marked Lanes 1st 17 Slow / Stopped Vehicle 7) No Controls 17) Tire Chains/Snow Req. nd 14 Motor Vehicle in Transport (Moving Vehicle) 8) Warning Sign 18) Permissive Green 3rd 308 Median Barrier 9) Turn Signal 4th 10) Other 5th 1) NRS ) CFR 3) CC / MC 4) Pending (1) NRS Following too close ) NRS ) CFR 3) CC / MC () Investigator(s) ID Number Date Reviewed By Date Reviewed Penny Cotter c Larry Hill of 6 VEHICLE INFORMATION

6 Name: (Last Name, First Name, Middle Name Suffix) Moore Carey Jane Greg Street Restraints: 05 B Location: 3 4 s: Name: (Last Name, First Name, Middle Name Suffix) Moore Jason Chris Greg Street Restraints: 05 B Location: 3 4 Name: (Last Name, First Name, Middle Name Suffix) s: Restraints: Location: s: 1) Trailing Unit 1 1) Trailing Unit 1) Trailing Unit 3 Commercial Vehicle Configuration 1) Commercial Vehicle ) School Bus 1) Bus, 9-15 s 6) Tractor Only 11) Tractor / Semi Trailer Source ) Bus, > 15 s 3) Single Axle and 6 Tire 4) Single > 3 Axle 5) Any 4 Tire Vehicle 7) Tractor / Trailer 8) Tractor / Doubles 9) Tractor / Triples 10) Truck with Trailer 1) Passenger Vehicle, (Haz-Mat) 13) Light Truck, (Haz-Mat) 14) Other Heavy Vehicle 1) Driver ) Log Book 3) Shipping Papers / Trip Manifest 4) State Reg. 5) Side Of Vehicle Carrier Name: Carrier Power Unit GVWR 1) < 10,000 Lbs ) 10,000-6,000 Lbs 3) > 6,000 Lbs City Zip: 1) Haz-Mat ) Released Cargo Body Type Haz-Mat ID #: Type of Carrier NAS Safety Report #: 1) Pole ) Tank 3) Flatbed 6) Van / Box 7) Concrete Mixer 8) Auto Carrier 11) Grain, Gravel Chips 1) Bus, 9-15 s 13) Bus, > 15 s Hazard Classification #: 1) Single State ) USDOT 3) Canada Carrier Number: 4) Dump 9) Garbage/Refuse 14) Other 10) Not Applicable Vehicle Information 4) Mexico 5) None 6 of 6