State of West Virginia Uniform Traffic Crash Report DOH Form: 17-c Revised: 02/2007 Crash Data Crash Record Number: Reporting Agency's Record Number: Page of Date / Time of Crash: GPS Coordinates: Route: / Milepost: Street: Date / Time Crash Reported: County: Highway Class: Interstate US WV County/HARP State Park / Forest Road City Street Private Road Other Private Property/Off-Roadway Municipality or Place of Crash: Supplemental Designation: Not Applicable Spur North East Truck Route Other Alternate Ramp South West Toll Intersection Type: 4-Way Intersection T Intersection Y Intersection Intersection as Part of Interchange Traffic Circle / Roundabout 5-Point or More Relation to Junction / Junction Type: Non-Junction Junction, Non-Interchange Area Junction, Interchange Area Intersection Intersection-Related Interstate to Interstate Railroad Grade Crossing Median Crossover-Related Business or Residential Driveway/Alley Access Other Non-Interchange Thru Roadway Merge/Diverge Area Intersection Intersection-Related Entrance / Exit Ramp Other Part of Interchange First Harmful Event: Bridge Overhead Structure Overturn / Rollover Pedestrian Bridge Pier or Support Fire / Explosion Pedalcycle Bridge Rail Immersion Railway Vehicle Jackknife Animal Cargo / Equipment Loss or Shift Motor Vehicle in Transport Fell / Jumped from Motor Veh Parked Motor Vehicle Thrown or Falling Object Work Zone / Maintenance Equip Other Non-Collision Other Non-Fixed Object Impact Attenuator / Crash Cushion Concrete Traffic Barrier Other Traffic Barrier Tree (Standing) Culvert Utility Pole/Light Support Curb Traffic Sign Support Ditch Traffic Signal Support Embankment Other Post, Pole, or Support Guardrail Face Fence Guardrail End Mailbox Cable Median Barrier Other Fixed Object Location of First Harmful Event: On Roadway Roadside In Parking Lane or Zone Outside of Right-of-Way Shoulder Gore Off Roadway, Location Unknown Median Separator Unknown Manner of Collision: Angle (Front to Side) Same Direction Right Angle Single Vehicle Crash Rear End Head-On Sideswipe, Same Direction Angle (Front to Side) Opp. Direction Angle - Direction Not Specified Sideswipe, Opposite Direction Rear-to-Side Rear-to-Rear OR OR OR Weather (Select Up to 2): Other Clear Rain Blowing Snow Cloudy Sleet, Hail, or Freezing Rain Severe Crosswinds Fog, Smog, Smoke Snow Blowing Sand, Soil, Dirt Lighting: Daylight Dawn Dark - Lighted Dusk Dark - Not Lighted Other Environmental Contributing Circumstances (Select Up to 3): None Weather Conditions Physical Obstruction(s) Glare Animal(s) in Roadway Other: Type: COLLISION WITH: / / Roadway Surface Condition: Dry Slush Mud, Dirt, Gravel, Sand Wet Ice / Frost Snow Water (Standing / Moving) #: Other Description of Location: Time of Arrival: Intersecting Street: Ramp: Latitude Longitude # of Vehicles Involved: # of Non-Motorists Involved: # of Fatal Injuries: # of A B or C Injuries: Roadway Surface Type: Asphalt Concrete Gravel Dirt Brick Other: Sample
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State of West Virginia Uniform Traffic Crash Report DOH Form: 17-cRevised: 02/2007
Crash DataCrash Record Number: Reporting Agency's Record Number: Page of
Date / Time of Crash:
GPS Coordinates:
Route: / Milepost: Street:
Date / Time Crash Reported:
County:
Highway Class: Interstate US WVCounty/HARP State Park / Forest RoadCity StreetPrivate Road OtherPrivate Property/Off-Roadway
Municipality or Place of Crash:
Supplemental Designation:
Not Applicable Spur North East Truck Route OtherAlternate Ramp South West Toll
Intersection Type:
4-Way IntersectionT IntersectionY IntersectionIntersection as Part of InterchangeTraffic Circle / Roundabout5-Point or More
Relation to Junction / Junction Type:
Non-Junction Junction, Non-Interchange Area Junction, Interchange Area
IntersectionIntersection-RelatedInterstate to InterstateRailroad Grade CrossingMedian Crossover-RelatedBusiness or Residential Driveway/Alley AccessOther Non-Interchange
Thru RoadwayMerge/Diverge AreaIntersectionIntersection-RelatedEntrance / Exit RampOther Part of Interchange
First Harmful Event: Bridge Overhead StructureOverturn / Rollover Pedestrian Bridge Pier or SupportFire / Explosion Pedalcycle Bridge RailImmersion Railway VehicleJackknife AnimalCargo / Equipment Loss or Shift Motor Vehicle in TransportFell / Jumped from Motor Veh Parked Motor VehicleThrown or Falling Object Work Zone / Maintenance EquipOther Non-Collision Other Non-Fixed Object
Culvert Utility Pole/Light SupportCurb Traffic Sign SupportDitch Traffic Signal SupportEmbankment Other Post, Pole, or SupportGuardrail Face FenceGuardrail End MailboxCable Median Barrier Other Fixed Object
Location of First Harmful Event:
On Roadway Roadside In Parking Lane or Zone Outside of Right-of-WayShoulder Gore Off Roadway,
Location UnknownMedian Separator Unknown
Manner of Collision: Angle (Front to Side) Same Direction Right Angle
Single Vehicle CrashRear EndHead-OnSideswipe, Same Direction Angle (Front to Side) Opp. Direction Angle - Direction
Not SpecifiedSideswipe, Opposite DirectionRear-to-SideRear-to-Rear
OR
OR
OR
Weather (Select Up to 2):OtherClear Rain Blowing Snow
Cloudy Sleet, Hail, or Freezing Rain Severe CrosswindsFog, Smog, Smoke Snow Blowing Sand, Soil, Dirt
Lighting:
Daylight DawnDark - Lighted DuskDark - Not Lighted Other
Environmental Contributing Circumstances (Select Up to 3):
NoneWeather ConditionsPhysical Obstruction(s)GlareAnimal(s) in Roadway
Crash Record Number: Reporting Agency's Record Number: Page of
Reported By: State Police Sheriff's DeptMunicipal PD Other
ORI Number:
School Zone Speed Limit:
School Bus Related:
NoYes, School Bus Directly InvolvedYes, School Bus Indirectly Involved
School Zone Related:
NoYes
Type of School Zone Sign:
When Present NoneWhen FlashingLists Specific Times
School Zone Flashers:
Present, Not ActivePresent, ActiveNot Present
Work Zone Related:
NoYes
Location of Crash in Work Zone:
Before 1st Warning Sign Activity AreaAdvance Warning Area Termination
AreaTransition (Merge) Area
Type of Work Zone:Intermittent orMoving WorkLane Closure
Lane Shift / Crossover OtherWork on Shoulder or in Median
Workers Present:
YesNoUnknown
Work Zone Speed Limit:
CRASH DIAGRAM:(Draw Crash Scene - Including Roadway Layout, Vehicles, Individuals or Objects Struck, Traffic Controls, etc.)IMPORTANT: Number Vehicles According to the Numbers Assigned on this Form.
Draw Arrow PointingNorth in Box
NARRATIVE: Describe What Happened. Refer to Vehicles by Number Assigned on this Form.
Road - Contributing Circumstances: (Select Up to 3) Work ZoneShouldersNone Ruts, Holes, BumpsRoad Surface Condition (Wet, Icy, etc.)
Worn, Travel Polished SurfaceProblem w/ Traffic Control DeviceObstruction in Roadway
Non-Highway WorkDebris Pavement Markings Not Visible
OtherInoperative ObscuredMissing
None Low Soft HighUtility
ConstructionMaintenance
Investigating Officer's Name:
Agency:
Date of Submission:
Number:
Photos Taken: Yes No
Video Taped: Yes No
By Whom:
By Whom:
Phone:
Assisting Officer's Name(s):
The information contained in this report reflects my best knowledge and judgment:
Reconstructed: Yes No By Whom:
Signature:
Sample
DOH Form: 17-vehRevised: 02/2007State of West Virginia Uniform Traffic Crash Report
Vehicle DataCrash Record Number: Reporting Agency's Record Number:Vehicle Number: Page of
VIN Reg YearLicense Plate Number
Model YearModel
Total / MaxOccupants of Veh:
Applicable Speed Limit (MPH):
Vehicle Type: Motor Veh in Transport Parked Motor Veh / Trailer Working Veh / Equipment
State
Make Body Type Color
Special Function of Motor Vehicle:
None Police Courtesy PatrolUsed as School Bus Ambulance TaxiUsed as Other Bus Fire Truck Military
Used as an Emergency Vehicle:
No Yes
Direction of Travel Before Crash:
Northbound Eastbound Not on RoadSouthbound Westbound Unknown
Roadway Description:
Two-Way, Not Divided Two-Way, Divided, Unprotected MedianTwo-Way, Not Divided w/ Cont. Left Turn Lane
Two-Way, Divided, with Median BarrierOne-Way Roadway
Horizontal Alignment:
Straight Curve RightCurve Left
Vertical Alignment:
Level Uphill Sag (Bottom)Hillcrest Downhill
For Undivided Highways: Count Total Lanes in Both Directions. (Excluding Designated Turn Lanes)For Divided Highways: Count Only Lanes in Direction Vehicle was Traveling Prior to Crash.
Traffic Control Device Type:
None Yield SignPerson (Flagger, etc.) School Zone SignsTraffic Control Signal Warning SignsFlashing Overhead Signal Railroad Crossing DeviceStop Sign Other
Traffic Control Functioning Properly: Yes No
Vehicle Maneuver / Action:
Essentially Straight Ahead Making U-TurnBacking SlowingChanging Lanes Stopped in TrafficOvertaking / Passing Leaving Traffic LaneParked Entering Traffic LaneTurning Right Negotiating a CurveTurning Left Other
Underride / Override:
No Underride or Override Underride, Compartment Intrusion UnknownUnderride, Compartment Intrusion Override, Motor Vehicle in TransportUnderride, No Compartment Intrusion Override, Other Motor Vehicle
Hit and Run: No, Did Not Leave SceneYes, Driver Left SceneYes, Car and Driver Left Scene
Extent of Damage
No DamageMinor DamageFunctional DamageDisabling Damage
Contributing Circumstances, Motor Vehicle (Select up to 2):
Driven Towed Due to Damage Towed Due to Driver Condition Left at Scene
Towed to: Towed by:
Exp Date:
Vehicle Used as a Bus:
Commuter BusPublic School Bus Tour BusShuttle BusPrivate School Bus Church BusModified for Personal/Private UseScheduled Service Bus
Vehicle Impact Role:
Striking Single VehicleStruck Both
Number of Axles:
Crash Avoidance Maneuver:
None Evident or ReportedBraking - Skidmarks EvidentBraking - Driver StatedBraking - Other EvidenceSteering - Evidence or StatedSteering and BrakingOther
Veh Travel Speed (MPH):
Modified Vehicle:
NoYes
Total Lanes in Roadway:
/
GVWR or GCWR:
Less Than or Equal To 10,000lbs
10,001 - 26,000 lbsMore Than 26,000lbs
Vehicle is Primarily Used to Transport Goods, Property, or People for Commerce:
Crash Record Number: Reporting Agency's Record Number:Vehicle Number: Page of
13 Top
14 Undercarriage
Select the ONE Diagram that best matches the involved vehicle and identify damaged areas:
Using the Numbers from the Diagram Above, Identify the Following: Area of Initial Impact: Most Damaged Area:
01 Overturn / Rollover02 Fire / Explosion03 Immersion04 Jackknife05 Cargo/Equipment Loss or Shift06 Equipment Failure07 Separation of Units08 Ran Off Road Right09 Ran Off Road Left
29 Curb30 Ditch31 Embankment32 Guardrail Face33 Guardrail End34 Cable Median Barrier35 Concrete Barrier36 Other Traffic Barrier37 Tree (Standing)38 Utility Pole / Light Support
39 Traffic Sign Support40 Traffic Signal Support41 Other Post, Pole, or Support42 Fence43 Mailbox44 Other Fixed Object
Most Harmful Event:
Sequence of Events:
10 Cross Median / Centerline11 Downhill Runaway12 Fell / Jumped from Motor Vehicle13 Thrown or Falling Object14 Other Non-CollisionCOLLISION WITH:15 Pedestrian16 Pedalcycle17 Railroad Vehicle18 Animal
Number of Trailing Units:
Carrier / Owner's Name:Same as Power UnitTrailing Unit #1:
VIN YearLicense Plate Number Model YearModelState Make Body Type
Carrier / Owner's Name:Same as Power Unit
Plate Class
Trailing Unit #2:
Carrier / Owner's Name:Same as Power UnitTrailing Unit #3:
Crash Events:
Property Damaged Other Than Vehicles:
NoneWork Zone / Maintenance EquipmentImpact Attenuator / Crash CushionBridge / TunnelCulvertGuardrailConcrete BarrierCable Median BarrierOther Traffic BarrierUtility Pole / Light Support
Traffic Sign SupportTraffic Signal SupportOther Post, Pole or SupportFenceMailboxOther Fixed Object
Damaged Property Owner(s):
WVDOHCityOther:
PrivateUtility Company
Damaged Property Location:
On Pavement
Left Side of RoadRight Side of Road
13 Top
14 Undercarriage
13 Top
14 Undercarriage
13 Top
14 Undercarriage
13 Top
14 Undercarriage
VIN YearLicense Plate Number Model YearModelState Make Body Type
Address:City State Zip Code
Phone:
Plate Class
VIN YearLicense Plate Number Model YearModelState Make Body TypePlate Class
Address:City State Zip Code
Phone:
Address:City State Zip Code
Phone:
19 Motor Vehicle in Transport20 Parked Motor Vehicle21 Struck by Falling / Shifting Cargo or Anything Set in Motion by Veh22 Work Zone / Maintenance Equip23 Other Non-Fixed Object24 Impact Attenuator / Crash Cushion25 Bridge/Overhead Structure26 Bridge Pier or Support27 Bridge Rail28 Culvert
Single Unit Vehicle Motorcycle Pass. Veh, Towing Unit Bus Tractor TrailerATV
#:
Sample
DOH Form: 17-drvRevised: 02/2007State of West Virginia Uniform Traffic Crash Report
Action(s) of Driver that Contributed to the Crash: (Select Up to 4)
None Improper Turn Operated Veh in Aggressive MannerRan Off Road Improper Backing
Failed to Yield Right of Way Improper Passing Swerved or AvoidedDisregarded Traffic Signs Wrong Side or Wrong Way Over Correcting /
Over SteeringRan Red Light Followed Too CloselyDisregarded Other Road Markings Failed to Keep in Proper Lane Other Improper ActionExceeded Posted Speed Limit Operated Veh in Erratic, Reckless,
or Careless MannerDrove Too Fast For Conditions
Driver Condition at Time of Crash:
Apparently NormalEmotionalIllFell Asleep, Fainted, FatiguedUnder the Influence of Medication/Alcohol/Drugs
Other
Alcohol Use Suspected:
NoYesUnknown
Alcohol Test Given:
Test GivenNone GivenTest Refused
Type of Alcohol Test Given (Select Up to 2):
BloodSerum
BreathField
UrineOther:
BAC Results:
__________PendingUnknown
Drug Use Suspected:
NoYesUnknown
Drug Test Given:
Test GivenNone GivenTest RefusedUnknown if Tested
Type of Drug Test Given:
Blood DRESerumUrineOther
Drug Test Results (Check All that Apply):
NoneMarijuanaCocaineOpiate
AmphetaminePCPOther Controlled SubstanceOther Drug
Pending
Driver Distracted By: Not Distracted Other Electronic Device Other Outside VehicleElectronic Communication Device Other Inside Vehicle
Lic. Number:Class:
A B C
License Restrictions: (Select All that Apply)
None Limited - OtherCorrective Lenses CDL Intrastate OnlyMechanical Devices Motor Vehicles w/o Air BrakesProsthetic Aid Military Vehicles OnlyAutomatic Transmission Except Class A BusOutside Mirror Except Class A and Class B BusLimit to Daylight Only Except Tractor - Trailer
Farm WaiverLimit to EmploymentMust Be Accompanied by Adult Other
Endorsements: (Select Up to 5)
NoneT - Double/Triple TrailersP - Passenger VehicleS - School BusN - Tank VehicleH - Hazardous MaterialsX - Combined Tank / Haz. MaterialsF - Motorcycle (WV Only)Other - Non-WV Licenses Only
Negligent HomicideReckless Driving; Driving to Endanger; Negligent Driving
Inattentive, Careless, Improper DrivingFleeing or Eluding Law EnforcementFailure to Obey Law Enforcement, Fireman, Authorized Person Directing TrafficHit and Run, Failure to Stop After AccidentSerious Violation Resulting in Death
Reckless/Careless/Hit and Run Type Offenses
Driving While Intoxicated (Alcohol or Drugs) or BAC Above Limit
Driving While ImpairedDriving Under Influence of Controlled Substance
Drinking While OperatingIllegal Possession of Alcohol or DrugsDriving with Detectable Alcohol (CDL or Under 21 Years of Age)Refusal to Submit to Chemical Test
Impairment Offenses
RacingSpeeding (Above Speed Limit)Speed Greater than Reasonable and PrudentExceeding Special LimitDriving too Slowly
Failure to Maintain Control of Vehicle
Speed Related Offenses
Failure to Stop for Red SignalFailure to Stop for Flashing Red SignalViolation of Turn on RedFailure to Obey Flashing Signal (Yellow or Red)Failure to Obey Signal, GenerallyViolation of RR Grade Crossing Device or RegulationsFailure to Obey Stop Sign
Rules of the Road - Traffic Signs and Signals
Failure to Obey Yield SignFailure to Obey Traffic Control Device
Turn in Violation of Traffic ControlImproper Method and Position of TurnFailure to Signal for Turn or StopFailure to Yield to Emergency VehicleFailure to Yield, GenerallyEnter Intersection when Space Insufficient
Rules of the Road - Turning, Yielding, Signaling
Driving Wrong Way on One-Way RoadDriving on Left, Wrong Side of Road, GenerallyImproper, Unsafe PassingPassing on Right (Drive Off of Pavement to Pass)Passed Stopped School BusFailure to Give Way When OvertakenFollowing Too CloselyWrong Side, Passing, Following Violations, Generally
Rules of the Road - Wrong Side, Passing and Following
Unsafe or Prohibited Lane ChangeImproper Use of LaneCertain Traffic to Use Right LaneLane Violations, Generally
Rules of the Road - Lane Usage
Driving While License Suspended or RevokedOther Driver License RestrictionsCommercial Driver ViolationsVehicle Registration ViolationsFailure to Carry Insurance CardDriving Uninsured VehicleNon-Moving Violations, Generally
Non-Moving License and Registration Violations
Lamp ViolationsBrake ViolationsFailure to Require Restraint UseMotorcycle Equipment ViolationsViolation of Hazardous Cargo RegulationsSize, Weight, Load ViolationsEquipment Violations, Generally
Equipment
ParkingTheft, Unauthorized Use of Motor VehicleDriving Where ProhibitedOther Moving Violation
DOH Form: 17-nmRevised: 02/2007State of West Virginia Uniform Traffic Crash Report
Non-Motorist DataCrash Record Number: Reporting Agency's Record Number: Page of
PersonType
NameIndiv # Birthdate Gender Injury
ActionPRIORto Crash
MedicalTransport By
Person Type Codes:
05 Pedestrian06 Other Pedestrian (Wheelchair, Skater, etc.)07 Bicyclist
08 Other Cyclist
Safety Equipment Used (Select Up to 2):
02 None Used03 Helmet04 Protective Pads
05 Reflective Clothing06 Lighting07 Other
Non-Motorist Location at Time of Crash:
01 Marked Crosswalk at Intersection02 At Intersection, but No Crosswalk03 Non-Intersection Crosswalk
01 Not Transported02 EMS03 Law Enforcement
05 Other06 Unknown
Age
04 Driveway Access Crosswalk05 In Roadway (Not in Crosswalk or Intersection)06 Median 09 Sidewalk
10 Roadside11 Outside of Trafficway12 Dedicated Bike Lane
13 Shared-Use Path or Trails14 Inside Building
Last First Mid. Int. Suffix
Gender:
M MaleF Female
Social Security #
09 Occupant of Non-Motor Veh Transportation Device10 Unknown Type of Non-Motorist
Actions of Non-Motorist that Contributed to the Crash (Select Up to 2):
02 Improper Crossing03 Darting / Running04 In Roadway (Stand, Sit)
05 Failure to Yield Right of Way06 Not Visible07 Inattentive08 Failure to Obey Traffic Signs, Signals, or Officer
09 Wrong Side of Road10 Other
Non-Motorist Action PRIOR to Crash:
03 Recreational Pursuit04 Walking To/From School
07 Cycling08 Working
06 Pushing Motor Vehicle05 Approaching or Leaving Veh 09 Playing
10 Standing
12 Other
ContributingActions
#1 #2
Indiv #from
Above
07 Island08 Shoulder
15 Other
16 Unknown
Locationat Timeof Crash
01 Not Applicable
Use of SafetyEquipment
Veh Numberof Motor Veh
Striking
Injury Status Codes:
K Killed A Incapacitating InjuryB Non-Incapacitating InjuryO No Injury
M Medical Condition Non-Crash Related Death or InjuryC Possible Injury
01 None
#1 #2
Traffic Control Device
RespondingEMS Agency
ID # Receiving Facility NameEMS ResponseRun Number
Date ofDeath
NotifiedTime
SceneTime
HospitalTime
Place of Victim's Death:
01 At Scene02 En Route03 At Medical Facility
04 Home05 Other
Time ofDeath
Place ofDeath
Non-Motorist's Traffic Control Device (Select Up to 2):
11 Working on Vehicle
01 Walking Adjacent to Roadway
LocationPRIORto Crash
01 Marked Crosswalk02 Traffic Signal with Pedestrian Signals03 Traffic Signal with NO Pedestrian Signals04 Crossing Guard
Non-Motorist Location PRIOR to Crash:
01 In Roadway02 Other Adjacent to Roadway
#1 #2
04 Refused
02 Entering or Crossing Roadway
Medically Transported By:
05 None
Sample
Crash Record Number: Reporting Agency's Record Number: Page of
Conditionat Timeof Crash
SuspectedY/N
Indiv #fromFront
Non-Motorist Condition at Time of Crash:
1 Apparently Normal
3 Emotional4 Ill5 Asleep, Fainted, Fatigued6 Under the Influence of Medication/Alcohol/Drugs7 Other
2 Physically Impaired
Alcohol Test Given: Type of Alcohol Test Given:
BAC Results:
Drug Test Given: Type of Drug Test Given:
TestGiven
Type ofTest
BACResults
Alcohol Related
02 None Given03 Test Refused
01 Test Given 01 Blood05 Urine02 Serum06 Other03 Breath
Enter BAC Level if AvailableP PendingU Unknown
SuspectedY/N
TestGiven
Type ofTest
Test ResultsDrug Related
02 None Given01 Test Given 03 Test Refused
04 Unknown if Tested01 Blood
03 Urine02 Serum
04 DRE
Reckless/Careless/Hit and Run Type Offenses
Impairment Offenses
Rules of the Road - Traffic Signs and Signals
Rules of the Road - Turning, Yielding, Signaling
Rules of the Road - Lane Usage Equipment
Other Violations
Violation(s) Suspected of or Committed by Non-Motorist:
Citation NumberState Code /
Municipal OrdinanceCharge Warning
Citation(s) Issued to Non-Motorist
01 No Violations
02 Inattentive, Careless, Improper Driving03 Fleeing or Eluding Law Enforcement04 Failure to Obey Law Enforcement, Fireman, Authorized Person Directing Traffic
05 Illegal Possession of Alcohol or Drugs06 Refusal to Submit to Chemical Test07 Public Intoxication
08 Failure to Stop for Red Signal09 Failure to Stop for Flashing Red Signal10 Violation of Turn on Red11 Failure to Obey Flashing Signal (Yellow or Red)12 Failure to Obey Signal, Generally13 Violation of RR Grade Crossing Device or Regulations14 Failure to Obey Stop Sign15 Failure to Obey Yield Sign16 Failure to Obey Traffic Control Device
20 Turn in Violation of Traffic Control21 Failure to Signal for Turn or Stop22 Failure to Yield to Emergency Vehicle23 Failure to Yield, Generally
17 Unsafe or Prohibited Lane Change18 Improper Use of Lane19 Lane Violations, Generally
24 Bicycle Helmet Violations25 Equipment Violations, Generally
27 Driving Where Prohibited28 Other Moving Violation
Indiv #from
Above
Violations Suspected of orCommitted by Non-Motorist#1 #2 #3 #4
26 Jaywalking
Drug Test Results:
01 None
03 Cocaine02 Marijuana
04 Opiate05 Amphetamine
07 Other Controlled Substance
06 PCP08 Other Drug09 Pending
1 2 3 4
04 Field05 Other
NameLast First
Sample
DOH Form: 17-cmvRevised: 02/2007State of West Virginia Uniform Traffic Crash Report
Commercial Motor Vehicle (CMV) DataCrash Record Number:
Reporting Agency's Record Number:
Vehicle Number (from Vehicle Data Page) Page of
US DOT Number: State ID Number:
Haz Mat Released from Cargo Compartment:
NoYesUnknown
Commercial Vehicle Configuration
Passenger Veh w/ Haz Mat Placard Single Unit Truck Pulling a Trailer
Light Truck w/ Haz Mat Placard
Bus/Large Van (Seats 9-15, Including Driver)
Bus (Seats More Than 15, Including Driver)
Truck Tractor (Bobtail)
Single Unit Truck (2 Axles, 6 Tires)
Truck Tractor w/ Semi-Trailer
Single Unit Truck (3 or More Axles)
Truck Tractor w/ Double
Truck Tractor w/ Triple
Piggy Back
Truck - Can't Classify
Carrier Name:
Carrier Address:City State Zip Code
Carrier Classification
Interstate IntrastateGovernment Veh - Not in CommerceOther Veh - Not in Commerce
Haz Mat Placard Number: Did Crash Occur on a Coal Resource Transportation System (CRTS) Route?
No Yes Unknown
Carrier Information Source: Shipping Papers
Log Book Lease Driver Vehicle Reg
Vehicle Side Other:
US DOT Number:
State ID Number:
Lessee / Lessor Name:
Address:City State Zip Code
Sample
Crash Record Number:
Reporting Agency's Record Number:
Vehicle Number (from Vehicle Data Page) Page of
Gross Combination Weight Rating (GCWR) - All Units:Gross Vehicle Weight Rating (GVWR) of Power Unit:
Commercial Cargo Body Type:
Not Applicable Garbage / RefuseBus (Seats for 9-15, Including Driver)
Grain, Chips, GravelBus (Seats for More Than 15, Including Driver)
PoleVan / Enclosed Box
LogCargo Tank
Flatbed Intermodal Chassis
DumpVehicle Towing Motor Vehicle
No Cargo BodyConcrete Mixer
Auto Transporter Other
Last Known Commodity: Cargo Compartment Empty or Full at Time of Crash: Empty Full
# of Passengers in CMV: Passengers Traveling with Written Permission of Carrier: Yes No
CMV Self Insured: No Yes Proof of Self Insurance: Yes No
Sample
DOH Form: 17-dgrmRevised: 02/2007State of West Virginia Uniform Traffic Crash Report
DiagramCrash Record Number
Reporting Agency's Record Number:Page of
CRASH DIAGRAM:(Draw Crash Scene - Including Roadway Layout, Vehicles, Individuals or Objects Struck, Traffic Controls, etc.)IMPORTANT: Number Vehicles According to the Numbers Assigned on this Form.