[ DO OT WRITE I THIS SPACE ] () Reporting Agency Case (Agency Use) Incident Report Investigation Completed Investigation Made at Scene Photographs Motor s Involved Y Injured Revised Fatality Hit and Run Killed Y () Date Collision (mm/dd/yyyy) Time County and ame earest or Town and ame () Distance from earest or Town Limits () Occupants Type Control # Int ID At Mi. E Ft. S W Last ame First Middle ear Location East Grid rth Grid Administrative Mi. Mi. E + + Ft. S Ft. W. () Street, Road or Highway Distance from (earest) Intersecting Street, Road or Highway Hit & Run In CMV () Address State Zip (7) Driver License State Class Endorsement(s) Restriction(s) Inj. Sev. Type Injury Drv./Ped. Cond. (8) Ejected Extricated Test (% BAC) Air Bag () VI () Insurance Verification () Removed by Driver. Insurance Company ame Transported by License Plate State Month Year Year Color nd Color Make Model Veh. Conf. Extent Damage Policy Insurance Owner's Last ame First Middle Initial () Owner's Address Oversized Load Towed Veh. Type Rolled Burned Phone present Phone in use () Citation () Occupants Type Hit & Run Citation Last ame First Middle CMV () Address State Zip () Driver License State Class Endorsement(s) Restriction(s) Inj. Sev. Type Injury Drv./Ped. Cond. (7) Ejected Extricated Test (% BAC) Transported by License Plate State Month Year Air Bag (8) VI () Insurance Verification. Year Color nd Color Make Model Veh. Conf. Extent Damage Insurance Company ame Policy Insurance () Removed by Owner's Last ame First Middle Initial Driver () Owner's Address Towed Veh. Type Oversized Rolled Load Burned () Citation Citation () Investigating Officer Badge Troop/Div. Reviewed by (Init.) Reviewer Badge Date Report (mm/dd/yyyy) Phone present Phone in use Type Injury Severity D Driver Z Cyclist /A Incapacitating P Pedestrian C Parked Car Injury Fatal X Pedestrian A Animal Possible Conveyance T Train n - B Bicyclist incapacitating WARIG - STATE LAW Type Injury /A Head Trunk - External Trunk - Internal Arms Legs Driver/Pedestrian Condition t Applicable Under the Ill (Sick) Apparently rmal Influence Dizzy/Faint Drinking - Ability Impaired Medications Emotional Odor Alcohol Beverage Very Tired Illegal Drugs 7 Sleepy Air Bag Deployed Ejected Extricated Chemical Test Extent Damage Insurance Verification Oversized Load Towed Type t Applicable Deployed - (knee, t Applicable Ejected, /A /A Test Refused /A Functional /A Operator /A /A Another Cattle Trailer t Deployed air belt, etc.) t Ejected Totally Blood ne Given ne Disabling Exempt t Permitted Boat Trailer Utility Trailer in Tow Deployed - Front Deployed - Combination Ejected, Breath Minor Owner P Permitted House Trailer 7 Homemade Deployed - Side Deployment Partially Blood/Breath Farm Trailer Trailer Horse Trailer Box Trailer Use contents for commercial solicitation is unlawful Occupant Protection (OP) In Use t Applicable Child Restraint Type ne Used Restraint Type Lap Belt Only 7 Helmet Shoulder Belt Only Child Restraint - Forward Facing Shoulder and Lap Belt Child Restraint - Rear Facing Booster Seat
Case () Pos in Veh. Last ame First Middle Initial () Address () Injury Severity / Type (7) Pos in Veh. Last ame First Middle Initial (8) Address () Injury Severity / Type () Pos in Veh. Last ame First Middle Initial () Address () Injury Severity / Type () Pos in Veh. Last ame First Middle Initial () Address () Injury Severity / Type Complete information below if this vehicle is being used for COMMERCE/BUSIESS and has a GVWR/GCWR I EXCESS OF, LBS., or has a HAZMAT PLACARD, or is a BUS WITH SEATIG FOR IE OR MORE ICLUDIG THE DRIVER () Carrier ame Address (7) - K lbs. Axle Qty. Cargo Body GVWR, - K lbs. GCWR K+ lbs. (8) U.S. DOT Inspection Placard Haz. Mat. Class Haz. Mat. Involved Haz. Mat. Release () Carrier ame OK Address Use Interstate Commerce Intrastate Commerce n-commercial Government () - K lbs. Axle Qty. Cargo Body GVWR, - K lbs. GCWR K+ lbs. () U.S. DOT Inspection Placard Haz. Mat. Class Haz. Mat. Involved Haz. Mat. Release OK Use Interstate Commerce Intrastate Commerce n-commercial Government Position in Configuration Cargo Body Type. /A. /A. Passenger Veh.- Dr. Passenger Veh.- Dr. Passenger Veh. Conv. 7. School Bus. Truck/Trailer. Truck-Tractor (Bobtail). Bus/Large Van - occupants including driver. Bus + occupants including driver 8. Farm Machinery. ATV. SUV. Bus - seats. Bus + seats. Intermodal 7. Dump Truck/ Trailer. Hopper (grain/ chips/gravel). Pole Trailer. t Applicable 8. Front Row - 8. Second Row - 8. Thrid Row - 8. Fourth Row -. Pickup. Single Truck, axles. Single Truck, + axles. Truck-Tractor/ Semi-Trailer. Truck-Tractor/ Double. Truck-Tractor/ Triple. Motorcycle. Motor Scooter/ Moped 7. Motor Home. Passenger Van. Truck more than, lbs., Cannot Classify. Van, lbs. or Less... Van/Enclosed Box. Cargo Tank. Flatbed. Concrete Mixer. Auto Transporter. Garbage/Refuse. Log Trailer. Towing..
Case This unit will correspond to '' This unit will correspond to '' 7 7 7 7 Light Daylight Dark-t Lighted Dark-Lighted Dawn Dusk Dark- Lighting Weather Clear Fog/Smog/Smoke Cloudy Rain Snow Sleet/Hail (Freezing Rain/Drizzle) Severe Crosswind Blowing Snow Blowing Sand, Soil, Dirt Locality Residential Business Industrial School t Built-up Mixed Use Type Intersection t an Intersection Y-Intersection T-Intersection Four-Way Intersection Five-Point, or More Intersection as Part Interchange Traffic Circle Roundabout Incident Type t an Incident Private Property Deliberate Intent Medical Condition Legal Intervention Suicide 7 Drowning 8 Location First Harmful Event 7 On Roadway Shoulder Median Roadside Gore Separator Parking Lane/Zone Off Roadway, Location Outside Right- Way Total Lanes in Roadway What Was Going to Do t Applicable Go Ahead Turn Left Turn Right Make U Turn Stop Slow for Cause 7 Start from Park/Stop Change Lanes Overtake Pass Back Remain Stopped Remain Parked Enter/Merge in Traffic egotiate a Curve Park 7 What Did t Applicable Went Ahead Turned Left Turned Right Entered U Turn Stopped Slowed 7 Started From Park/Stop Entered Lane Overtaking Passing Backed Remained Stopped Remained Parked Entered/Merged Departed Rdwy-Right Departed Rdwy-Left 7 Swerved Right 8 Swerved Left Parked Visibility Obscured by 7 t Applicable Trees Embankment Building Signs Parked s High Weeds Fences Shrubbery Ice, Snow or Frost on Windows Smoke Fog Dust Rain Sun Driver Distracted by Legal Speed Actions Prior to Collision t Applicable/ne Electronic Communication Devices Electronic Device Inside Outside 7 Pedestrian / Pedalcyclist Only Location at Time Safety Collision Equip. Underride/ Override t Applicable Underride or Override Underride, Compartment Intrusion Underride, Compartment Intrusion Underride, Compartment Intrusion Override, Motor in Transport Override, Motor Traffic Control Control Stop Sign Traffic Signal Flashing Traffic Signal School Zone Signs Yield Sign Warning Sign Railroad Advance Warning Sign Railroad Cross Bucks Railroad Gates Railroad Signal Passing Zone Person (including flagger, law enforcement, crossing guard, etc.) Abnormal Control Posted Speed Road Surface Conditions Dry Wet Ice/Frost Snow Mud, Dirt, Gravel Slush 7 Water (standing, moving) Sand Oil Road Character Grade Level Hillcrest Uphill Downhill Sag (bottom) Horizontal Alignment Straight Curve - Left Curve - Right Road Surface Type Concrete Asphalt Gravel Dirt Brick Striking Trafficway Removal Condition Was the collision in or near a construction, maintenance or utility work zone? (If yes, complete this section) Type Work Zone Lane Closure Lane Shift/Crossover Work on Shoulder or Median Intermittent or Moving Work t Applicable Two-Way, t Divided Two-Way, t Divided with a Continuous Left Turn Lane Two-Way, Divided, Unprotected (painted > feet) Median Two-Way, Divided, Positive Median Barrier Two-Way, Divided, Cable Barrier One-Way t Applicable Towed Due to Damage Towed For Reasons Than Damage Remained at Scene Driven from Scene Special Function 7 t Applicable School Bus Transit Bus Intercity Bus Charter Bus Bus Military OHP Police Law Enforcement Ambulance Fire Truck Public Owned Highway Equipment Special Mobilized Machine Emergency Responding to an Emergency /A Workers Present t Applicable Apparently rmal Brakes Headlights Steering Tail Lights Brake Lights 7 Tires/Wheels Suspension Signal lights Windows Truck Coupling/Trailer Hitch/Safety Chains Mirrors Wipers Power Train Point First Contact on Most Damaged Area Unsafe / Unlawful Contributing Factors FAILED TO YIELD 7 FOLLOWED TOO CLOSELY Human Element Traffic Condition Weather Condition USAFE SPEED 7 8 7 8 IMPROPER TUR 7 8 TRAFFIC LAE FAILED TO STOP From Stop Sign From Yield Sign Private Drive County Road at Through Highway From Signal Light From Alley To Pedestrian To on Right To in Intersection To Emergency s Driver's Ability (Age) Inexperienced Driver - Young Exceeding Legal Limit For Traffic Conditions For Type Roadway (Gravel, Dirt, etc.) For Ice or Snow on Roadway Rain or Wet Roadway Wind Weather Conditions Condition View Obstruction On Curve/Turn Impeding Traffic From Wrong Lane From Direct Course Right Left Turn About/U-Turn To Enter Private Drive In Front Oncoming Traffic CHAGED LAES USAFELY STOPPED I For Stop Sign For Traffic Signal For School Bus For Railroad Gates/ Signal For Officer/Flagman At Sidewalk/Stopline USAFE VEHICLE 7 Brakes 8 Steering Top Undercarriage Location the Work Zone Collision Before the First Work Zone Warning Sign Advance Warning Area Transition Area Activity Area Termination Area n-collision Tires Suspension Headlights Tail Lights Stop Lights Wheel Exhaust System Windshield Wipers 7 Mechanical Defects LEFT OF CETER 8 In Meeting Passing Zone (Unmarked) Marked Zone IMPROPER OVERTAKIG In Marked Zone On Hill/Curve At Intersection Without Sufficient Clearance IMPROPER PARKIG 7 On Roadway 8 Where Prohibited IATTETIO 7 Distracted by Passenger in 7 Distraction Inside 7 Distraction From Outside 7 WROG WAY 7 On One Way 7 On Exit Ramp 7 On Entrance Ramp 77 IMPROPER START FROM 78 Parked Position 7 8 ALCOHOL-DUI/DWI 8 DRUG-DUI OTHER IMPROPER ACT/ MOVEMET 8 Failed to Signal 8 Disregarded Warning Signal 8 Improper Use Lane 8 Improper Backing 8 Apparently Sleepy 87 Failed to Secure Load 88 UK./O IMPROPER ACT 8 7 8 Deer in Roadway Animal in Roadway Domestic Animal in Rdwy Avoiding Avoiding Pedestrian Object/Debris in Roadway Defect in Roadway Abnormal Traffic Control Improper Bicyclist Action O IMPROPER ACTIO BY DRIVER PEDESTRIA ACTIO
Case Latitude. Longitude. W Railroad Crossing Direction Travel Before Collision E S W E S W Indicate rth by Arrow COLLISIO EVETS 7 8 Remarks First Event Second Event Third Event Fourth Event Overturn/Rollover Fire/Explosion Immersion Jackknife Cargo/Equipment Loss or Shift Equipment Failure (Blown Tire, Brake Failure, etc.) Separation s Departed Road Right Departed Road Left Cross Median/Centerline Downhill Runaway First Harmful Event First Event Second Event Third Event Fourth Event First Harmful Event First Harmful Event for the Entire Collision Fell/Jumped From Motor Thrown Or Falling Object n-collision PERSO, MOTOR VEHICLE, OR O- FIXED OBJECT: Pedestrian Pedal Cycle Railway (train, engine) Animal Motor in Transport Parked Motor Struck by Falling, Shifting Cargo or Anything Set in Motion by Motor 7 Work Zone/Maintenance Equipment n-fixed Object 8 FIXED OBJECT: 7 8 Barrier (Cable) Barrier (Concrete) Barrier () Fence Pole Fence Traffic Signal Support Traffic Sign Support Utility Pole/Light Support Post/Pole/Support Guardrail/Guardrail Face Guardrail End Culvert Curb Island Sand Barrels Impact Attenuator/ Crash Cushion 7 8 7 8 7 7 7 7 Pavement Drop-Off Ditch Embankment Tree (Standing) Dividing Strip Retaining Wall Bridge Abutment Bridge Pier or Support Bridge Rail Bridge Post Bridge Curb Bridge Super Structure (Beams) Bridge Overhead Structure Delineator Mailbox Fixed Object Highway Structure Ground 7
Case PERSOS SUPPLEMETAL () Pos in Veh. Last ame First Middle Initial Injured Witness () Address Passenger Prop. Owner State Zip () Injury Severity / Type () Pos in Veh. Last ame First Middle Initial () Address (7) Injury Severity / Type (8) Pos in Veh. Last ame First Middle Initial () Address () Injury Severity / Type () Pos in Veh. Last ame First Middle Initial () Address () Injury Severity / Type () Pos in Veh. Last ame First Middle Initial () Address () Injury Severity / Type (7) Pos in Veh. Last ame First Middle Initial (8) Address () Injury Severity / Type () Pos in Veh. Last ame First Middle Initial () Address () Injury Severity / Type () Pos in Veh. Last ame First Middle Initial () Address () Injury Severity / Type () Pos in Veh. Last ame First Middle Initial (7) Address (8) Injury Severity / Type 8
Case DIAGRAM SUPPLEMETAL Indicate rth by Arrow
Case ADDITIOAL ARRATIVE