Rhode Island Uniform Crash Report 12/2006

Report Number1 Driver2 Passenger3 Pedestrian4 Bicyclist5 Other Cyclist6 WitnessSTATE OF RHODE ISLAND UNIFORM CRASH REPORTAdditional Persons SupplementalPerson Type7 Other Ped. (Wheelchair, Person in Building, Skater, 9 Occupant of a Non-Motor Veh Transportation DevicePed. conveyance, etc.)10 Unknown Type of Non-Motorist8 Occupant of Motor Veh. Not in Transport (Parked, etc.) 11 UnknownUnit ID1 Unit 12 Unit 23 (etc.)or N/ASexM MaleF FemaleU UnkM1 2 34 5 67 8 910 11 12Name: Occupants - Witnesses -Pedestrians - BicyclistsSeat PositionOther Location13 Other Row 17 N/A(Bus) 18 Sleeper14 Unk Row 19 Other Enclosed Area15 Other Seat 20 Other Unenclosed Area16 Unk Seat 21 Towed Unit22 UnkPersonTypeAir BagDeployed1 N/A2 No3 Front4 Side5 Other6 Comb7 UnkEjected1 No2 Partially3 Totally4 N/A5 UnkUnit ID Sex DOB SeatPos.Protection System1 N/A2 None Used3 Shoulder & Lap4 Shoulder Only5 Lap Only6 Type Unk7 Child - Forw Facing8 Child - Rear Facing9 Booster Seat10 Child - Unk11 Helmet Used12 Other13 UnkEjectedAir BagDeployedProt.SystemInjuryInjury1 Complains of Pain2 Non-Incapacitating3 Incapacitating4 Fatal5 No Injury6 UnkTrans byRescueYYYYYYYYYYYYYYYYYYNNNNNNNNNNNNNNNNNNNon-Vehicle Property Damage State Property City/Town Property Private PropertyOwnerAddressHome Phone Cell Phone Work Phone Damage DescriptionNon-Vehicle Property Damage State Property City/Town Property Private PropertyOwnerAddressHome Phone Cell Phone Work Phone Damage DescriptionNon-Vehicle Property Damage State Property City/Town Property Private PropertyOwnerAddressHome Phone Cell Phone Work Phone Damage DescriptionPage 6

State of Rhode IslandTruck/Bus Crash Report SupplementalReport Number: MCSAP #: Unit ID:Citation Issued (check one):License Class (check one):Yes No Pending Unknown A B C D MGeneral Instructions - Complete this form for EACH qualifying vehicle if the crash meets the criteria on the back of the form.Qualifying InformationCheck one:This form is being completed because this vehicle is: Number of: (enter number in box provided)A truck or truck combination > 10,000 lbs. GVWR/GCWRTotal involved vehicles in the crash:A bus with seats for 9 or more persons, including driver Persons sustaining fatal injuries:A vehicle of any type with a Hazardous Materials Placard Injured persons transported for immediate medical treatment:(includes auto, light truck, van, 10,000 lbs. or less)Vehicles towed from scene due to disabling damage:At the time of the Crash, THIS Vehicle was:Operating on a Trafficway open to the public (In-Transport)Vehicle InformationParked on or off the TrafficwayVehicle Configuration: (enter one code from below) Cargo Body Type: (enter one code from below)1 Passenger Car (only if vehicle has Hazardous Materials Placard) 1 Bus (seats for 9-15 people, including driver)2 Light Truck (only if vehicle has Hazardous Materials Placard) 2 Bus (seats for 16 people or more, including driver)3 Bus (seats for 9-15 people, including driver) 3 Van/Enclosed Box4 Bus (seats for 16 people or more, including driver) 4 Cargo Tank5 Single-Unit Truck (2 axles, 6 tires) 5 Flatbed6 Single-Unit Truck (3 or more axles) 6 Dump7 Truck/Trailer(s) [Single-Unit Truck with Trailer(s)] 7 Concrete Mixer8 Truck Tractor (without trailer, bobtail or saddlemount) 8 Auto Transporter9 Tractor/Semi-Trailer (one trailer) 9 Garbage/Refuse10 Tractor/Doubles (two trailers) 10 Grain, Chips, Gravel11 Tractor/Triples (three trailers) 11 Pole99 Other Truck > 10,000 lbs. (not listed above) 12 Not Applicable/No Cargo BodyGVWR/GCWR(use GCWR for truck combinations):13 Intermodal Chassis14 Logging1 10,000 lbs. or less 15 Vehicle Towing Another Motor Vehicle2 10,001 - 26,000 lbs. 98 Other Cargo Body (not listed above)3 Greater than 26,000 lbs.Hazardous Materials Involvement:Bus Use:Did the vehicle have a Haz Mat Placard? YES NOIf YES, include the following information from the Placard:0 Not a Bus 3 IntercityA. HM 4-Digit # or name from diamond or box:1 School (Public or Private) 4 CharterB. HM Class # from bottom of diamond:2 Transit 5 OtherWas Haz Mat released from THIS vehicle's cargo? YES NOCheck one:Carrier Name:Motor Carrier InformationInterstate Carrier Intrastate Carrier Not in Commerce-Government Not in Commerce-Other Trucks(Over 10,000 lbs. GVWR/GCWR)Carrier Street Address (P.O. Box only if no street address):City/State/Zip:Phone:Carrier Identification Number(s): NONE USDOT# MC/MX# STATE#Sequence of EventsNote: For THIS vehicle - list up to four: Event 1 Event 2 Event 3 Event 4Non-Collisions Non-Collisions (cont.) Collision Involving/With (cont.)1 Ran Off Road 8 Cross Median/Centerline 15 Train2 Jackknife 9 Equipment Failure (tire, brakes, steering, etc.) 16 Pedalcycle3 Overturn (Rollover) 10 Other Non-Collision 17 Animal4 Downhill Runaway Collision Involving/With 18 Fixed Object5 Cargo Loss or Shift 12 Pedestrian 19 Work Zone Maintenance Equipment6 Explosion or Fire 13 Motor Vehicle In-Transport 20 Other Moveable Object7 Separation of Units 14 Parked Motor Vehicle 98 OtherPage 7

IF THIS CRASH INCLUDES:Reporting Criteria forTruck and Bus Crashes1 Any truck having a gross vehicle weight rating (GVWR) of more than 10,000 pounds or a gross combinationweight rating (GCWR) over 10,000 pounds used on public highways,2 Any motor vehicle with seats to transport nine (9) or more people, including the driver's seat,3 Any vehicle displaying a hazardous materials placard (regardless of weight).And at least one motor vehicle in-transport operating on a trafficway open to the public, which results in:A FATALITY:AN INJURY:Any person(s) killed in or outside of any vehicle (truck, bus, car, etc.) involved in the crash or who diesORwithin 30 days of the crash as a result of an injury sustained in the crash,Any person(s) injured as a result of the crash who immediately receives medical treatment away fromthe crash scene, ORA TOW-AWAY: Any motor vehicle (truck or truck combination, bus, car, etc.) disabled as a result of the crash andtransported away from the scene by a tow truck or other vehicle.Vehicle ConfigurationCargo Body TypePage 8