Alaska Crash Report, Revised 9/12/2001 - NHTSA

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ALASKA MOTOR VEHICLE COLLISION REPORTDMV #: Incident/Case #Driver Information (One choice per field unless otherwise noted – Other * should be explained in narrative)Unit #: Driver Name (Last, First, MI): Sex: DOB: Contact Phone:01 M 02 FOL / ID #: State: LicenseClass:01 CDL-A02 CDL-B03 CDL-C04 CDL-IC05 D06 MI07 M208 IM09 IP Ejected: 01 Y 02 N 03 P 04 UnkExtricated: 01 Y 02 N 03 UnkMailing Address: City: State: Zip: NFR: Ins Coverage:01 Y 02 N 01 Y 02 NPhysical Address: City: State: Zip: Ins Company:Environment Circumstances: Injury Status Driver Restraint / Airbag (4 choice max):01 Glare 04 None05 None02 Obstruction 05 Other *06 Not Reported03 Weather 06 Unk07 Unk01 Fatal02 Incapacitating *03 Non-incapacitating *04 Possible01 Not used02 None instld03 Helmet04 Lap/Shldr05 Lap only06 Shldr only07 Prp Chld Rst08 Imp Chld RstAlcohol/Drugs Suspected: Test Given: BAC Level: Transported:09 A/bag Dplyd10 A/bag not Dplyd11 A/bag switch off12 Side bag Dplyd01 None 02 Alcohol 03 Drugs 04 Both 01 Blood 02 Breath 03 Not given 04 Refused 01 Y 02 N 03 Unk13 Not Reported14 UnkHuman Circumstances (2 choice max): Transported By: Transported To:01 No improper driving02 Backing unsafely03 Cell phone use04 Disregard traffic control device other than signal05 Driver inattention06 Driver inexperience07 Drove off road08 Emotional09 Failure to yield10 Fell asleep11 Following too closely12 Illness13 Improper lane usage/change14 Improper passing15 Improper turn16 Loss of consciousness17 Passenger distraction18 Pedestrian error/confusion19 Physical disability20 Red light violation21 Stop sign violation22 Taking prescription meds23 Unsafe speed24 Wrong side/way25 Other *26 Unk01 Air Ambulance02 Airplane03 EMS04 Helicopter05 Police06 Private vehicle07 Unk08 N?A01 Clinic02 Hospital03 Mortuary04 Residence05 Unk06 N/AVehicle InformationVehicle Damage: No. of Occupants: Vehicle Owner Name (Last, First, MI): Contact Phone:01 None/Minor02 Functional03 Disabling04 Totaled05 UnkMailing Address: City: State: Zip:Damage Estimate: VIN: License Plate #: State:Over $501Undercarriage Damage Veh Year: Make: Model: Color:01 Y 02 NDirection of Travel: Veh Towed: 01 Y 02 N 03 Unk01 North 03 East 05 Unk(Circle codes to show first impact – select one) 02 South 04 WestTowed By:Vehicle Configuration (non-commercial only): Vehicle Configuration (commercial only):Body Type (2 choice max, commercial only):01 Dog sled07 Pedalcycle 01 Single-unit (2-axles)07 Tractor/triples01 Auto transporter07 Dump13 Unk02 Light truck (only 4 ties03 Motorhome04 Motorcycle05 Off highway vehicle06 Passenger car08 Pedestrian09 Other *10 Unk02 Single unit (3+ axles)03 Truck/trailer04 Tractor (bobtail)05 Tractor/semi-trailer06 tractor/doubles08 Van/enclosed box09 Unk heavy truck10 Other *11 Unk02 Bus (15 or more seats)03 Bus (7-15 seats)04 School bus05 Cargo tank06 Concrete mixer08 Flatbed09 Garbage/refuse10 Grain/chips/gravel11 Pole12 Other *Vehicle Circumstances:Vehicle Action:FRONT01 Accelerator defective02 Brakes defective03 Headlights defective04 Other lighting defective05 Oversized vehicleRoadway Circumstances:01 Debris02 Inoperative traffic device03 Missing traffic device04 Obscured traffic device06 Steering failure07 Tire failure/inadequate08 Tow hitch defective09 Windshield damage10 None05 Obstruction in roadway06 Shoulder07 Road surface condition08 Ruts, holes, bumpsCommercial Vehicle Information11 Other *12 Unk09 School zone10 Work zone11 Worn, polished12 None(If crash involves a commercial vehicle, complete this section and forward a copy ofreport to CVE Unit, 12050 Industry Way – Bldg O – Suite #6, Anch, AK 99515)Carrier Name:Gross Weight (lbs):Address:Carrier ID#:City: State: Zip: Contact Phone:REAR01 Avoiding objects in road02 Backing03 Changing lanes04 Entering traffic lane05 Leaving traffic lane13 Other *14 Unk06 Making U-turn07 Merging08 Out of control09 Passing10 ParkedTraffic Control01 Flashing signal02 No controls03 Road const signs04 RR crossing deviceSecond Sequence of Events, Collision01 Aircraft02 Animal03 Bicyclist04 Bridge/Overpass05 Bridge rail06 Crash cushion07 Culvert08 Curb/Wall09 Ditch10 Embankment11 Fence22 Sign12 Guard rail face13 Guard rail end14 Light support15 Machinery16 Mail box17 Median barrier18 Moose19 Parked vehicle20 Pedestrian21 SideswipeCarrier ID Source: Issuing Authority Placard: Haz Mat Released: Second Sequence of Events, Non-collision:01 Driver/Vehicle02 Log Book03 Shipping Papers04 Trip Manifest01 US DOT02 ICC03 AKS01 Y02 N03 Unk01 Y02 N03 Unk33 Cargo loss/shift34 Crossed median/centerline35 Downhill runaway36 Equipment failure11 Skidding12 Slowing13 Starting in traffic14 Stopped15 Straight ahead05 School zone signs06 Stop sign07 Traffic control signal08 Warning signs37 Explosion/fire38 Immersion39 Jackknife40 Overturn16 Turning right17 Turning left18 Other *19 Unk23 Snowberm24 Traffic signal pole25 Train26 Tree/shrub27 Utility pole28 Veh in transit29 Veh - rear end30 Veh – head on31 Veh – angle32 Other fixed object09 Yield sign10 Officer/flagman/guard11 Other *12 Unk41 Ran off road42 Separation of units43 Other *44 UnkPage ________ of ________ 12-200 Revised 9/12/01Part B
ALASKA MOTOR VEHICLE COLLISION REPORTDMV #: Incident/Case #Driver Information (One choice per field unless otherwise noted – Other * should be explained in narrative)Unit #: Driver Name (Last, First, MI): Sex: DOB: Contact Phone:01 M 02 FOL / ID #: State: LicenseClass:01 CDL-A02 CDL-B03 CDL-C04 CDL-IC05 D06 MI07 M208 IM09 IP Ejected: 01 Y 02 N 03 P 04 UnkExtricated: 01 Y 02 N 03 UnkMailing Address: City: State: Zip: NFR: Ins Coverage:01 Y 02 N 01 Y 02 NPhysical Address: City: State: Zip: Ins Company:Environment Circumstances: Injury Status Driver Restraint / Airbag (4 choice max):01 Glare 04 None05 None02 Obstruction 05 Other *06 Not Reported03 Weather 06 Unk07 Unk01 Fatal02 Incapacitating *03 Non-incapacitating *04 Possible01 Not used02 None instld03 Helmet04 Lap/Shldr05 Lap only06 Shldr only07 Prp Chld Rst08 Imp Chld RstAlcohol/Drugs Suspected: Test Given: BAC Level: Transported:09 A/bag Dplyd10 A/bag not Dplyd11 A/bag switch off12 Side bag Dplyd01 None 02 Alcohol 03 Drugs 04 Both 01 Blood 02 Breath 03 Not given 04 Refused 01 Y 02 N 03 Unk13 Not Reported14 UnkHuman Circumstances (2 choice max): Transported By: Transported To:01 No improper driving02 Backing unsafely03 Cell phone use04 Disregard traffic control device other than signal05 Driver inattention06 Driver inexperience07 Drove off road08 Emotional09 Failure to yield10 Fell asleep11 Following too closely12 Illness13 Improper lane usage/change14 Improper passing15 Improper turn16 Loss of consciousness17 Passenger distraction18 Pedestrian error/confusion19 Physical disability20 Red light violation21 Stop sign violation22 Taking prescription meds23 Unsafe speed24 Wrong side/way25 Other *26 Unk01 Air Ambulance02 Airplane03 EMS04 Helicopter05 Police06 Private vehicle07 Unk08 N?A01 Clinic02 Hospital03 Mortuary04 Residence05 Unk06 N/AVehicle InformationVehicle Damage: No. of Occupants: Vehicle Owner Name (Last, First, MI): Contact Phone:01 None/Minor02 Functional03 Disabling04 Totaled05 UnkMailing Address: City: State: Zip:Damage Estimate: VIN: License Plate #: State:Over $501Undercarriage Damage Veh Year: Make: Model: Color:01 Y 02 NDirection of Travel: Veh Towed: 01 Y 02 N 03 Unk01 North 03 East 05 Unk(Circle codes to show first impact – select one) 02 South 04 WestTowed By:Vehicle Configuration (non-commercial only): Vehicle Configuration (commercial only):Body Type (2 choice max, commercial only):01 Dog sled07 Pedalcycle 01 Single-unit (2-axles)07 Tractor/triples01 Auto transporter07 Dump13 Unk02 Light truck (only 4 ties03 Motorhome04 Motorcycle05 Off highway vehicle06 Passenger car08 Pedestrian09 Other *10 Unk02 Single unit (3+ axles)03 Truck/trailer04 Tractor (bobtail)05 Tractor/semi-trailer06 tractor/doubles08 Van/enclosed box09 Unk heavy truck10 Other *11 Unk02 Bus (15 or more seats)03 Bus (7-15 seats)04 School bus05 Cargo tank06 Concrete mixer08 Flatbed09 Garbage/refuse10 Grain/chips/gravel11 Pole12 Other *Vehicle Circumstances:Vehicle Action:FRONT01 Accelerator defective02 Brakes defective03 Headlights defective04 Other lighting defective05 Oversized vehicleRoadway Circumstances:01 Debris02 Inoperative traffic device03 Missing traffic device04 Obscured traffic device06 Steering failure07 Tire failure/inadequate08 Tow hitch defective09 Windshield damage10 None05 Obstruction in roadway06 Shoulder07 Road surface condition08 Ruts, holes, bumpsCommercial Vehicle Information11 Other *12 Unk09 School zone10 Work zone11 Worn, polished12 None(If crash involves a commercial vehicle, complete this section and forward a copy ofreport to CVE Unit, 12050 Industry Way – Bldg O – Suite #6, Anch, AK 99515)Carrier Name:Gross Weight (lbs):Address:Carrier ID#:City: State: Zip: Contact Phone:REAR01 Avoiding objects in road02 Backing03 Changing lanes04 Entering traffic lane05 Leaving traffic lane13 Other *14 Unk06 Making U-turn07 Merging08 Out of control09 Passing10 ParkedTraffic Control01 Flashing signal02 No controls03 Road const signs04 RR crossing deviceSecond Sequence of Events, Collision01 Aircraft02 Animal03 Bicyclist04 Bridge/Overpass05 Bridge rail06 Crash cushion07 Culvert08 Curb/Wall09 Ditch10 Embankment11 Fence22 Sign12 Guard rail face13 Guard rail end14 Light support15 Machinery16 Mail box17 Median barrier18 Moose19 Parked vehicle20 Pedestrian21 SideswipeCarrier ID Source: Issuing Authority Placard: Haz Mat Released: Second Sequence of Events, Non-collision:01 Driver/Vehicle02 Log Book03 Shipping Papers04 Trip Manifest01 US DOT02 ICC03 AKS01 Y02 N03 Unk01 Y02 N03 Unk33 Cargo loss/shift34 Crossed median/centerline35 Downhill runaway36 Equipment failure11 Skidding12 Slowing13 Starting in traffic14 Stopped15 Straight ahead05 School zone signs06 Stop sign07 Traffic control signal08 Warning signs37 Explosion/fire38 Immersion39 Jackknife40 Overturn16 Turning right17 Turning left18 Other *19 Unk23 Snowberm24 Traffic signal pole25 Train26 Tree/shrub27 Utility pole28 Veh in transit29 Veh - rear end30 Veh – head on31 Veh – angle32 Other fixed object09 Yield sign10 Officer/flagman/guard11 Other *12 Unk41 Ran off road42 Separation of units43 Other *44 UnkPage ________ of ________ 12-200 Revised 9/12/01Part B
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Alaska Crash Report, Revised 9/12/2001 - NHTSA

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