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

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ALASKA MOTOR VEHICLE COLLISION REPORTDMV #: Incident/Case #Passenger / Witness Information (One choice per field unless otherwise noted – Other * should be explained in narrative)Unit #: Name (Last, First, MI): Sex: 01 M 02 F OL/ID #: State:DOB:Person Type: Physical Address: City: State: Zip: Contact Phone:01 Passenger02 Witness Restraint / Airbag Information (4 choice max): Ejected: Injury Status Transported 01 Y 02 N 03 UnkSeat Location:Transported By:Transported To:01 Center front02 Right front03 Left rear04 Center rear05 Right rear06 Other *07 N/A08 Unk01 Not used02 None instld03 Helmet04 Lap/Shldr05 Lap only06 Shldr only07 Prp Chld Rst08 Imp Chld Rst09 A/bag Dplyd10 A/bag not Dplyd11 A/bag switch off12 Side bag Dplyd13 Not Reported14 Unk01 Y02 N03 P04 UnkExtricated:01 Y02 N03 Unk01 Fatal02 Incapacitating *03 Non-incapacitating *04 Possible05 None06 Not Reported07 Unk01 Air Ambulance02 Airplane03 EMS04 Helicopter05 Police06 Private vehicle07 Unk08 N/A01 Clinic02 Hospital03 Mortuary04 Residence05 Unk06 N/AUnit #: Name (Last, First, MI): Sex: 01 M 02 F OL/ID #: State:DOB:Person Type: Physical Address: City: State: Zip: Contact Phone:01 Passenger02 Witness Restraint / Airbag Information (4 choice max): Ejected: Injury Status Transported 01 Y 02 N 03 UnkSeat Location:Transported By:Transported To:01 Center front02 Right front03 Left rear04 Center rear05 Right rear06 Other *07 N/A08 Unk01 Not used02 None instld03 Helmet04 Lap/Shldr05 Lap only06 Shldr only07 Prp Chld Rst08 Imp Chld Rst09 A/bag Dplyd10 A/bag not Dplyd11 A/bag switch off12 Side bag Dplyd13 Not Reported14 Unk01 Y02 N03 P04 UnkExtricated:01 Y02 N03 Unk01 Fatal02 Incapacitating *03 Non-incapacitating *04 Possible05 None06 Not Reported07 Unk01 Air Ambulance02 Airplane03 EMS04 Helicopter05 Police06 Private vehicle07 Unk08 N/A01 Clinic02 Hospital03 Mortuary04 Residence05 Unk06 N/AUnit #: Name (Last, First, MI): Sex: 01 M 02 F OL/ID #: State:DOB:Person Type: Physical Address: City: State: Zip: Contact Phone:01 Passenger02 Witness Restraint / Airbag Information (4 choice max): Ejected: Injury Status Transported 01 Y 02 N 03 UnkSeat Location:Transported By:Transported To:01 Center front02 Right front03 Left rear04 Center rear05 Right rear06 Other *07 N/A08 Unk01 Not used02 None instld03 Helmet04 Lap/Shldr05 Lap only06 Shldr only07 Prp Chld Rst08 Imp Chld Rst09 A/bag Dplyd10 A/bag not Dplyd11 A/bag switch off12 Side bag Dplyd13 Not Reported14 Unk01 Y02 N03 P04 UnkExtricated:01 Y02 N03 Unk01 Fatal02 Incapacitating *03 Non-incapacitating *04 Possible05 None06 Not Reported07 Unk01 Air Ambulance02 Airplane03 EMS04 Helicopter05 Police06 Private vehicle07 Unk08 N/A01 Clinic02 Hospital03 Mortuary04 Residence05 Unk06 N/AUnit #: Name (Last, First, MI): Sex: 01 M 02 F OL/ID #: State:DOB:Person Type: Physical Address: City: State: Zip: Contact Phone:01 Passenger02 Witness Restraint / Airbag Information (4 choice max): Ejected: Injury Status Transported 01 Y 02 N 03 UnkSeat Location:Transported By:Transported To:01 Center front02 Right front03 Left rear04 Center rear05 Right rear06 Other *07 N/A08 Unk01 Not used02 None instld03 Helmet04 Lap/Shldr05 Lap only06 Shldr only07 Prp Chld Rst08 Imp Chld Rst09 A/bag Dplyd10 A/bag not Dplyd11 A/bag switch off12 Side bag Dplyd13 Not Reported14 Unk01 Y02 N03 P04 UnkExtricated:01 Y02 N03 Unk01 Fatal02 Incapacitating *03 Non-incapacitating *04 Possible05 None06 Not Reported07 Unk01 Air Ambulance02 Airplane03 EMS04 Helicopter05 Police06 Private vehicle07 Unk08 N/A01 Clinic02 Hospital03 Mortuary04 Residence05 Unk06 N/APage ________ of ________ Part C 12-200 Revised 9/12/01
ALASKA MOTOR VEHICLE COLLISION REPORTDMV #: Incident/Case #Check all that apply.Pedestrian InformationCrossing with SignalCrossing against signalCrossing, no signal, marked crosswalkCrossing, no signal or marked crosswalkWalking with trafficWalking against trafficEmerging in front of/behind parked vehicleChild getting on/off school busGetting on/off vehicle other than school busPushing/working on vehicleParking in roadwayPlaying in RoadwayPlaying in roadwayOther actions in roadwayNot in roadwayAlcohol involvedBike visibility flagBike helmet wornLand Usage at Accident LocationSchool / playgroundOne / two family residentialApartment residentialBusiness / shoppingIndustrial / manufacturingAgricultural / undevelopedRecreational / park / campingOther property damage $Non – highway Not investigated at scene Left sceneNumber of photographs taken by: Police OtherPage ________ of ________ Supplement 12-200 Revised 11/6/01
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Alaska Crash Report, Revised 9/12/2001 - NHTSA

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