Commonwealth of massachusetts motor vehicle crash operator report

Commonwealth of MassachusettsMotor Vehicle Crash Operator ReportWhen Should You File a Report■You should file a report if you’re the operator of a vehicle involved in a crash where the damage to any one vehicle orproperty is over $1000, or if there is an injury to any person, even if a police officer was on the scene. You should filethe report within 5 days of the date of the crash.When Should You NOT File a Report■You should not file a report if the crash occurred on a private road, driveway, private parking lot or other private way.Why this Report is ImportantData from this report is used for many purposes including:■Identifying locations with a large number of crashes.■Improving dangerous highways and intersections.■Developing highway safety public information programs.■Developing programs to save lives and reduce highway injuries.How To Complete This FormPlease carefully complete all sections of this form that apply to your crash, circling the answer where appropriate. Illegiblereports will be returned to you.Section A: Crash Location■Provide the city/town where the crash occurred,the date and time of the crash, and the number ofvehicles involved.■Complete section A1 or A2.■Use official names of all locations, streets andlandmarks.■Use street name and route #, if applicable.■Be as precise as possible when describing thelocation.■Provide enough information to locate the crashto a specific point, not just a street or roadway.Section B: Vehicle You Were Driving■Provide information on your license and thevehicle you were driving.■Use the codes provided to indicate the cause ofthe crash.Section C: You and Your Passengers■Provide information on you and your passengersat the time of the crash.■Use the codes provided to indicate occupantinformation.Section D: Other Vehicles Involved in theCrash■Provide information on the other vehicle(s) andoperator(s) involved in the crash.■If more than one vehicle involved, please useadditional form completing Section D only.Section E: Non-Motorist(s) Involved■Provide information on the non-motorist(s)involved in the crash.■If more than one non-motorist involved, pleaseuse additional form completing Section E only.CRA-23 #10365 G003402 05/02 MCISection F: Crash Conditions■Use the codes provided to indicate theconditions at the time of the crash.Section G: Crash Diagram■Draw a diagram of how the crash occurred.■On the diagram, Vehicle 1 represents yourvehicle.Section H: Witness Information■List all the people who saw the crash but werenot involved.Section I: Property Damage Information■Indicate all non-vehicular property that wasdamaged in the crash.Section J: Description of What Happened■Describe the crash including events prior to thecrash for your vehicles and all other vehicles.Section K: Signature■Please sign and print your name and indicate thedate you completed the form.Where to send completed reports:❑❑❑Mail or deliver one copy to your local policedepartment in the city or town where the crashoccurred.Mail one copy to your Insurance Company.Mail one copy to the RMV at the followingaddress:Crash RecordsRegistry of Motor VehiclesP.O. Box 55889Boston, MA 02205-5889Page 1

Section A: Crash LocationCity/Town Where Crash Occurred Date of Crash Time of Crash____ : ____ __ AM __ PMPlease complete Section A1 or A2 below to indicate the location of the crash.If you need additional space to describe the crash location, please use Section J on the last page of this form.SECTION A1: Complete this Section if the crashoccurred at an intersection of two or more streets:Step 1: Please indicate the route or roadway where youwere travelling when the crash occurred:____________Route#__________________________________Name of Roadway/StreetStep 2: What was the name (or names) of the intersectingstreets?____________Route#____________Route#__________________________________Name of Roadway/Street__________________________________Name of Roadway/StreetORSection B: Vehicle You Were Driving# VehiclesInvolved:SECTION A2: Complete this Section if the crash did NOT occur at anintersection:Step 1: Please indicate the route, roadway and address where the crash occurred:The crash occurred on Route #: _______ at Street or Address Number: ________________on the Street/Roadway known as: ______________________________________________Step 2: Please provide as much of the following specific location information as possible:The crash occurred (estimate number of feet)_______________ feet(indicate direction as N/S/E/W) _______________ ofa) Mile Marker number ___ ___ ___ ___OR: b) Exit Number________________OR: c) Intersecting Street/Roadway __________ ___________________________Route#Name of Roadway/StreetOR: d) Landmark _______________________________________________________Number of occupants in vehicle (including yourself): _________ Was vehicle damage above $1000? __Yes __NoDriver’s License Number License State Date of Birth Age Sex License Class Commercial Driver’s License Endorsements__ D __ A __B __C__ M __ FH __ Hazardous N __ Tank vehicles P__Passenger__ M __ Unknown T __ Doubles/Triples X __ Tank and Hazardous transportYour Full Name (Last, First, Middle) Street Address City/Town State ZipInsurance Company Vehicle Registration # Reg. Type Reg. State Vehicle Year Vehicle MakeIndicate your type of vehicle1 Passenger car 4 Bus (15 or more passengers) 8 Truck/trailer 12 Tractor/triples 97 Other2 Light truck (van, mini-van, 5 Bus (7-15 passengers) 9 Truck tractor (bobtail) 13 Unknown heavy truck 99 Unknownpick-up, sport utility) 6 Single-unit truck (2 axles) 10 Tractor/semi-trailer 14 Motor home/recreational vehicle3 Motorcycle 7 Single-unit truck (3 or more axles) 11 Tractor/doublesFull Name of Vehicle Owner (Last, First, Middle) Street Address City/Town State ZipVehicle Travel Direction__N __S __E __WWhat Was Your Vehicle Doing Prior to the Crash?1 Travelling straight ahead 4 Turning left 7 Leaving traffic lane 10 Backing 97 Other2 Slowing or stopped 5 Changing lanes 8 Making U-turn 11 Parked 99 Unknown3 Turning right 6 Entering traffic lane 9 Overtaking/passingPlease Indicate the Sequence of Events as they occurred to YOUR Vehicle by writing the corresponding number (1-52, or 97, 99) in up to 4 boxes below.What happened first? What happened 2 nd (if applicable)? What happened 3 rd (if applicable)? What happened 4 th (if applicable)?Collision with1 Motor vehicle in traffic2 Parked motor vehicle3 Pedestrian4 Cyclist5 Animal- deer6 Animal- other7 Moped8 Work zone maintenance equipment9 Railway vehicle (train, engine)10 Other movable object11 Unknown movable object20 Curb21 Tree22 Utility pole23 Light pole or other post/support24 Guardrail25 Median barrier26 Ditch27 Embankment/Sloping shoulder28 Highway traffic signpost29 Overhead sign support30 Fence31 Mailbox32 Crash cushion/Impact attenuator33 Bridge34 Bridge overhead structure35 Other fixed object (wall, building, tunnel)36 Unknown fixed objectNon-Collision40 Ran off road right41 Ran off road left42 Cross median/centerline43 Overturn/rollover44 Equipment failure (blown tire, brakes, etc)45 Fire/explosion46 Immersion47 Jackknife48 Cargo/equipment loss or shift49 Separation of units50 Downhill runaway51 Other non-collision52 Unknown non-collision97 Other99 UnknownWas your Vehicle Towed From the Scene Due to Damage? __Yes__NoVehicle Damaged Area(circle up to three)2 3 41 9 58 7 60 None10 Undercarriage11 Totaled97 Other99 UnknownPage 2

Driver (See previous page)Section C: You and Your PassengersPlease provide the full name, address, and DOB or Age for all passengers in your vehicle. Then write the corresponding code in each of the boxes for each occupant of the vehicle(yourself and all passengers). A list of the possible codes is provided at the bottom of this section.Date of SexBirth/Age M/FA B C D E F G H Name ofMedical FacilityName of Passenger 1 (Last, First, Middle)Name of Passenger 2 (Last, First, Middle)Name of Passenger 3 (Last, First, Middle)A. Seating Position1 Front seat - left side (or motorcycle driver)2 Front seat - middle3 Front seat - right side4 Second seat - left side (or motorcycle passenger)5 Second seat - middle6 Second seat - right side7 Third row - left side (or motorcycle passenger)8 Third row - middleE. Ejected From Vehicle?0 Not ejected1 Totally ejected2 Partially ejected3 Not applicable99 UnknownAddressCity/Town State ZipAddressCity/Town State ZipAddressCity/Town State Zip9 Third row - right side10 Sleeper section of cab11 Enclosed passenger area12 Unenclosed passenger area13 Trailing unit14 Riding on vehicle exterior97 Other99 UnknownF. Trapped?0 Not trapped1 Freed by mechanical means2 Freed by non-mechanical means99 UnknownB. Safety System Used0 None used1 Shoulder and lap belt2 Lap belt only3 Shoulder belt only4 Child safety seat5 Helmet99 UnknownG. Injured?1 Fatal injuryNon-fatal injury:2 Incapacitating 5 No injury3 Non-incapacitating 99 Unknown4 PossibleSection D: Other Vehicle(s) Involved in the CrashC. Air Bag Status1 Deployed-front2 Deployed-side3 Deployed bothfront and side4 Not deployed5 Not applicable99 UnknownD. Air Bag Switch1 Switch in ON position2 Switch in OFF position3 ON-OFF switch not present4 Unknown if switch is present99 UnknownH. Transported for Medical Care?1 Not transported 97 Other2 EMS (emergency service) 99 Unknown3 PoliceWas Vehicle DamageNumber of occupants in the Vehicle: _____ Number of injured occupants: _____ above $1000? __Yes ___No Moped? __Yes __No Hit and Run? __Yes __NoDriver’s License NumberLicense State Date of Birth Age Sex License ClassCommercial Driver’s License Endorsements__ D __ A __ B __ C__ M __ FH __ Hazardous N __ Tank vehicles P__Passenger__ M __ Unknown T __ Doubles/Triples X __ Tank and Hazardous transportFull Name of Vehicle Driver (Last, First, Middle) Street Address City/Town State ZipInsurance Company Vehicle Registration # Reg. Type Reg. State Vehicle Year Vehicle MakeIndicate type of vehicle1 Passenger car 4 Bus (15 or more passengers) 8 Truck/trailer 12 Tractor/triples 97 Other2 Light truck (van, mini-van, 5 Bus (7-15 passengers) 9 Truck tractor (bobtail) 13 Unknown heavy truck 99 Unknownpick-up, sport utility) 6 Single-unit truck (2 axles) 10 Tractor/semi-trailer 14 Motor home/recreational vehicle3 Motorcycle 7 Single-unit truck (3 or more axles) 11 Tractor/doublesFull Name of Vehicle Owner (Last, First, Middle) Street Address City/Town State ZipVehicle TravelDirection__N __S__E __WWhat Was the Vehicle Doing Prior to the Crash?1 Travelling straight ahead 4 Turning left 7 Leaving traffic lane 10 Backing 97 Other2 Slowing or stopped 5 Changing lanes 8 Making U-turn 11 Parked 99 Unknown3 Turning right 6 Entering traffic lane 9 Overtaking/passing__M __ FSection E: Non-Motorist(s) Involved in the CrashVehicle Damaged Area (circle up to three)2139450 None10 Undercarriage11 Totaled8 7 697 Other99 UnknownIndicate the type of non-motorist involved 1 Pedestrian 2 Cyclist 3 Skater 97 Other 99 UnknownWhat was the non-motorist doing prior to the crash?Where was the non-motorist prior to the crash?1 Entering or crossing location 6 Working on vehicle1 Marked crosswalk at intersection 6 Median (but not on shoulder)2 Walking, running, or cycling 7 Standing2 At intersection but no crosswalk 7 Island3 Working 97 Other3 Non-intersection crosswalk 8 Shoulder4 Pushing vehicle 99 Unknown4 In roadway 9 Sidewalk5 Approaching or leaving vehicle5 Not in roadway 10 Shared-use path or trails99 UnknownDate of Birth/Age Sex Full Name of Non-Motorist (Last, First, Middle) Street Address City/Town State ZipSafety Equipment?Injured?Transported for Medical Care?0 None used 9 Lighting1 Fatal injury1 Not transported 97 Other6 Helmet 10 OtherNon-fatal injury:2 EMS (emergency service) 99 Unknown7 Protective pads (elbows, knees, etc.) 99 Unknown 2 Incapacitating 5 No injury 3 Police8 Reflective clothing 3 Non-incapacitating 99 Unknown If transported, please indicate Hospital/Medical Facility:4 PossiblePage 3

Light Conditions1 Daylight2 Dawn3 Dusk4 Dark - lighted roadway5 Dark - roadway not lighted6 Dark - unknown roadwaylighting97 Other99 UnknownTrafficway Description1 Two-way, not divided2 Two-way, divided, unprotected median3 Two-way, divided, protected median4 One-way, not divided99 UnknownIndicateNorth byArrowWeather Conditions (up to two)1 Clear2 Cloudy3 Rain4 Snow5 Sleet, hail, freezing rain6 Fog, smog, smoke7 Severe crosswinds8 Blowing sand, snow97 Other99 UnknownSchool BusRelated?1 ___ Yes2 ___ NoSection F: Crash ConditionsTraffic Control Device1 No controls2 Stop signs3 Traffic control signal4 Flashing traffic control signal5 Yield signs6 School zone signs7 Warning signs8 Railroad crossing device99 UnknownWork ZoneRelated?1 ___ Yes2 ___ NoWas the trafficcontrol devicefunctioning atthe time of thecrash?1 ___ Yes2 ___ NoSection G: Crash DiagramRoad Surface1 Dry2 Wet3 Snow4 Ice5 Sand, mud, dirt, oil, gravel6 Water (standing, moving)7 Slush97 Other99 UnknownManner of Collision1 Single vehicle crash 6 Head on2 Rear-end 7 Rear to rear3 Angle 99 Unknown4 Sideswipe, same direction5 Sideswipe, opposite directionRoadway Intersection Type1 Not at intersection2 Four-way intersection3 T-intersection4 Y-intersection5 On ramp6 Off ramp7 Traffic circle8 Five-point or more9 Driveway10 Railway grade crossing99 UnknownPlease draw a diagram of theroadway or streets where the crashoccurred, indicating the vehiclesinvolved and direction of travelusing the following symbols:= Direction1 = Vehicle 1 (Your Vehicle)2 = Vehicle 2O = Pedestrian/Non-motorist= NorthSection H: Witness InformationWitness Name (Last, First, Middle) Address PhoneSelect one of the following ifthe crash did not occur on apublic way:___ Off-street parking lot___ Garage___ Mall/shopping center___ Other private waySection I: Property Damage Information (Other than Vehicles)Owner Name (Last, First, Middle) AddressPhone Property and Damage DescriptionSection J: Description of What HappenedSection K: Signature_______________________________________________“Signed under Pains and Penalties of Perjury”Print ________________________________________ Date ___________________________Page 4