Oregon Police Traffic Crash Report and Police …...7 Conversion Table for Feet to Miles: Miles Hundredths Feet Miles Hundredths Feet Miles Hundredths Feet Miles Hundredths Feet Miles

7

Conversion Table for Feet to Miles:

MilesHundredths Feet Miles

Hundredths Feet MilesHundredths Feet Miles

Hundredths Feet MilesHundredths Feet

1 Mile 5280 1/5 .20 1056 .40 2112 .60 3168 .80 4224.01 53 .21 1109 .41 2165 .61 3221 .81 4277.02 106 .22 1162 .42 2218 .62 3274 .82 4330.03 158 .23 1215 .43 2270 .63 3326 .83 4382.04 211 .24 1267 .44 2323 .64 3379 .84 4435.05 264 1/4 .25 1320 .45 2376 .65 3432 .85 4488.06 317 .26 1373 .46 2429 .66 3485 .86 4540.07 370 .27 1426 .47 2482 .67 3538 .87 4594.08 422 .28 1478 .48 2535 .68 3590 .88 4646.09 475 .29 1531 .49 2587 .69 3643 .89 4700

1/10 .10 528 .30 1584 1/2 .50 2640 .70 3696 .90 4752.11 581 .31 1637 .51 2693 .71 3749 .91 4805

1/8 .12 634 .32 1690 .52 2746 .72 3802 .92 4858.13 686 1/3 .33 1742 .53 2798 .73 3855 .93 4910.14 739 .34 1795 .54 2851 .74 3907 .94 4963.15 792 .35 1848 .55 2904 3/4 .75 3960 .95 5016.16 845 .36 1901 .56 2957 .76 4013 .96 5069

1/6 .17 898 .37 1954 .57 3010 .77 4066 .97 5122.18 950 .38 2006 .58 3062 .78 4118 .98 5174.19 1003 .39 2059 .59 3115 .79 4171 .99 5227

When crash occurred at an intersection: Write the name of the intersecting road in the ROAD ON WHICH CRASH OCCURRED. Chec the Within bo . When crash did not occur at an intersection: Write the name of the nearest intersecting road. Please do not use street address, PO BOX numbers, or landmar s. Chec the Near bo . Complete the Feet or Miles lines giving distances from the crash scene to the intersecting road and circle hether the crash location as N, S, E, or W of the intersecting road.

NEAREST CITY/TOWNThis element is critical to identify the crash location. Complete this section even if the crash did not occur inside a city or to n.When crash occurred inside cit or to n: Write the name of the city or to n. Chec the

ithin bo . When crash occurred outside cit or to n: Write the name of the nearest city or to n. Chec the Near bo . Complete the Feet or Miles lines giving distances from the crash scene to the city limits of the nearest city or to n and circle hether the crash location as N, S, E, or W of the city or to n.

8

Chec all that a l

Pro ert Damage: Chec this bo if the crash involved property damage other than vehicle damage and is not public property. Public Pro ert Damage: Chec this bo hen public property is damaged. Utili e this to assist in notifying the of cial responsible that city, county, or state property as damaged and should be e amined for repair or replacement. Traf c control signs, street lights, re hydrants, guardrails, and par ing meters are e amples of public property.If there is property damage over 00 to either public property or private property other than a vehicle, all drivers involved in the crash are re uired to report the crash to DMV. Estimate damage amount : For the amount of damage to public or private property, chec the over 500 damage bo or the under 500 damage bo . If you don t no , chec un no n. If both private and public properties are damaged, use the NARRATIVE to further e plain hen the damage amount is over 500 for one type of property but under 500 for the other.Hazardous Materials: Chec this bo if the crash involved a vehicle carrying ha ardous materials. Assume vehicles displaying the ha ardous materials placard contain ha ardous materials. Write the unit number(s) of the vehicle carrying ha ardous materials ne t to this bo , or include the information in the NARRATIVE.Photos Taken: Chec this bo if a la enforcement of cer ta es pictures.Train R/R: Chec this bo if the crash involved a train.Truck/Bus: Chec this bo if the crash involved a truc /bus.

UNIT #Assign a UNIT number to each driver, vehicle, pedestrian, bicyclist, damaged property or other involved in the crash. ODOT ill record the same basic data for each of these units, if applicable. On Form 735-46A (Appendi A) Page 1, there is space for collection

of information on t o units separated by a section labeled HIT AND RUN. If there are three units involved, you may utili e the supplemental Form 735-46B (Appendi B - Oregon Police Traf c Crash Report Addition). There are three entries for passenger/ itness information on Form 735-46A, Page 1. If there is a need for more entries, you can use the supplemental Form 735-46B to add the passenger/

itness information.Form 735-46B includes elds for the Police Incident/Case Number, Crash Date, and County in the crash information section. The UNIT and the PASSENGER/WITNESS sections are identical to Form 735-46A, Page 1. All instructions for Form 735-46B are the same as for Form 735-46A.If there are more than three units, continue unit identi cation and descriptions on additional face sheets of Form 735-46A. E ample: Add Unit 3 and Unit 4 on an additional face sheet. Utili e as many face sheets as needed to accommodate the number of units involved in the crash.

13

UNKNOWN: Chec this bo if it is not no n hether the driver of the identi ed UNIT as transported from the scene of the crash.

BY: If the driver of the identi ed UNIT as transported from the scene of the crash, enter the name of the Emergency Medical Service transportation provider (Buc Ambulance, Eugene Fire Department, etc.). TO: If the driver of the identi ed UNIT as transported from the scene of the crash, enter the name of the place and city here the in ured person as ta en (Sacred Heart Hospital-Eugene, Doctor s Clinic-Bend, doctor s of ce, etc., or un no n).

VEHICLE DAMAGEThe form sho s a top vie of an automobile diagram. If the vehicle is not an automobile, do your best to ma e the diagram or for you, or describe the damage in the NARRATIVE. Describe the overall e tent of the damage in the NARRATIVE. Use shading to indicate

here all damage to the identi ed UNIT occurred. Dra an arro to indicate the area of r timpact. There may or may not have been damage to the vehicle at the rst impact.Damage Estimate Mark all That A l lease estimate dollar damage even if ou have marked the vehicle as a rollover or totaled .NONE: Chec this bo to indicate that there ere no damages to the identi ed UNIT.UNDER $ 500: Chec this bo to indicate that you estimate the amount of damage to the identi ed UNIT at less than 500.OVER $ 500: Chec this bo to indicate that you estimate the amount of damage to the identi ed UNIT at more than 500. ROLLOVER: Chec this bo to indicate that the identi ed UNIT rolled over during the course of the crash. UNDERCAR: Chec this bo to indicate that there is damage to undercarriage of the identi ed UNIT.TOTALED: Chec this bo to indicate that the identi ed UNIT as totaled as a result of the crash. UNKNOWN: Chec this bo if information regarding the e tent of the damage to the identi ed UNIT is not no n.

INJURYThis section identi es the in ury status of the person listed in connection ith the identi ed UNIT. Use the same code descriptions for passengers as drivers.NONE: Chec this bo to indicate that there as no bodily harm to the driver of the identi ed UNIT. Do not consider the effects of disease such as stro e, heart attac , diabetic coma, epileptic sei ure, etc., as crash related in uries. COMPLAINT OF PAIN: Chec this bo to indicate any in ury claimed by the driver of the identi ed UNIT. E amples include momentary unconsciousness, complaint of pain, limping, nausea, etc.

14

VISIBLE INJURY: Chec this bo to indicate any in ury to the driver of the identi ed UNIT hich is evident to observers at the scene of the crash. E amples include a visible lump, abrasions, cuts, bruises, minor lacerations, etc. INCAPACITATED: Chec this bo to indicate any in ury to the driver of the identi ed UNIT that prevents the in ured party from al ing, driving, or normally continuing the activities he or she as capable of performing before the in ury occurred. E amples include bro en or distorted limbs, s ull or chest in uries, abdominal in uries, unconscious at or hen ta en from the crash scene, unable to leave crash scene ithout assistance, etc. FATAL: Chec this bo to indicate that the driver of the identi ed UNIT is deceased as a result of the crash. (Death does not have to have occurred at the scene of the crash.)

REMINDER: Send a teletype to LEDS for all fatal crashes ithin 24 hours. Fatality information includes motor vehicle traf c crashes that result in the death of an occupant of a vehicle or a non-motorist ithin 30 days of the crash.

EQUIPMENTThis section identi es the safety e uipment in use by the person listed in connection ith the identi ed UNIT at the time of the crash. Use the same code descriptions for passengers as drivers. Chec all that apply.NONE INSTLD: If the vehicle as ithout any safety e uipment installed.NO EQP USED: If safety e uipment as available but as not in use.UNKNOWN: If it is un no n hether safety e uipment as in use.LAP ONLY: If only a lap belt as in use.SHLDR ONLY: If only a shoulder harness as in use.LAP/SHLDR: If both a lap belt and shoulder harness ere in use.HELMET: If a helmet as in use.CHLD RST PRP: If a child restraint as in use and used properly.CHLD RST IMPR: If a child restraint as in use but used improperly.A/BAG DEPLYD: If an airbag as available and deployed.A/BAG NOT DP: If an airbag as available but did not deploy.

ACTION/ARREST/CITESRecord the basic information for any action ta en. For e ample, if a DUII citation as issued to the driver of this unit, rite citation-DUII. As space allo s, you may ish to also record the abstract number from the UTC or any other information that you ill need later to identify the citation.

HIT AND RUNThe purpose of this section is to identify that the crash involved a hit and run. If the crash involves a hit and run, complete this section ith any no n information

21

POLICE TRUCK/BUS/HAZMAT CRASH SUPPLEMENTAL The Police Truck/Bus/Hazmat Crash Supplemental e e e

e e e he e e T h e e e e e T h e h e

The e T h e he e T h e e h 2 h T The e e

he he he h e e e e he e e T h e h e e e e

e e h The Police Truck/Bus/Hazmat Crash Supplemental form should not be completed unless both incident and vehicle criteria are met.

QUALIFYING INCIDENT AND VEHICLE CRITERIA INCLUDE:

INCIDENT e h he h e e e e e he e e eh e e e e e e

ANDVEHICLE is:

e h 1 1 e eh e h e eh e h e e he e

If the crash does not meet both the incident and ualif in vehicle criteria, do not complete a Truck/Bus/Hazmat Crash Supplemental form orm .

POLICE INCIDENT/CASE NUMBERe e e e e e e e e Th e h

he e e e e e T h e ,

DAY OF WEEKThe e h h e e e e T h e ,

CRASH DATEe he e e he he ee h h he h e , e e he

e h h he h e , h, , e Th e h he e e e e e T h e ,

22

CRASH TIMEe he e he he h h e e e e e e

he h e e h , e 12 12 h h e e, e e he e h e e e

e e e e e

ROAD ON WHICH CRASH OCCURREDe he e e e e e e e e e e

e he e e e e e h e eT e e ee e T e e h e 2 e e e e e 22 e e 22 e e e

e e e e e e he h e e e , e he e e he he e he e e, T, he , he , he , he he e e he e he e e ee

VEHICLE INFORMATIONe e he eh e , e he e he e e

VEHICLE CONFIGURATIONe e he e eh e he eh e , e e

e e

VEHICLE DAMAGEThe h e eh e e h e he e

e he e e T e e he e The e h e ee e he eh e he

SEQUENCE OF EVENTS (for this vehicle)he he e e e e e h e 1 he e e ,

2 he e e e e e h e h e e he e e e e e , e e

CARRIER INFORMATIONMARK ALL THAT APPLY:

e e e e e e T ee e e he e 1 ,

NAME e he e he e

23

ADDRESS e he e , e e

IDENTIFICATION NUMBERS The e e e he e e he eh eNONE

he h e e e h e e eUS DOT

e e h e h he e e e e T eICC MC

e e h e h he e e e e e The e e he e he e e

DRIVER INFORMATIONNAME LAST FIRST MIDDLE

e e he e he e h e e e, he e h e e he e h he e e e he e e e e e h h he e e, e he e e e e he e e e

e, e , h, h ee he h h, h e

DRIVER LICENSE NUMBERe he e e e eh e e e e h e e e

Th e e e he e e h e he e e he e , e e e e he e e e

STATEe he e e e he e h e he e e e e e e e e e

CLASSe he e e e he e e e

ENDORSEMENTe he e e e e e e he e e e

MEDICAL CERTIFICATION EXP DATEe he e e e he e h e

CO-DRIVER INFORMATION e he eh e, e e he e e e he e

of the vehicle at the ti e of the c a h

DRIVER HOURS RECAPThi ectio ho l o l e co lete a of ce ho ha co lete the e o

e a t e t of T a o tatio t ai i a i a ce ti e i ecto f o have ot ha the t ai i a ee ce ti e , o ot co lete thi ectio f o a e ce ti e , chec off all violatio that a l f othe i chec e , ite i the violatio

24

OFFICER NAME/NUMBER/DATEi t the a e of of ce co leti thi fo a the of ce a e o i e ti catio e

e i ate o e a t e t ite the ate o co lete the e o t

AGENCYte a e of o olice a e c f o a eviate, e e the a eviatio i i e to o

a e c a le co l e e leto olice e a t e t, i eville olice e a t e t, etc

APPROVED BY (OPTIONAL)a e o i itial of e vi o e o el evie i a ovi the e o t

Appendix A

CF RF

OREGON POLICE TRAFFIC CRASH REPORTDMVPOLICE INCIDENT / CASE NUMBER DMV FILE NUMBERCRASH DATE

M T W TH FCRASH TIME POLICE NOTIFIED POLICE ARRIVAL

AMPM

AMPM

AMPM

ROAD ON WHICH CRASH OCCURRED

OF NEAREST INTERSECTING ROADWITHIN

NEAR

FEET

MILES

N S

E W

OF NEAREST CITY / TOWNWITHIN

NEAR

FEET

MILES

N S

E W

DMV CODECOUNTY MILE POST

PAGE OF

ADDRESS

SUSPECT NAME AKA IN CUSTODYY N

HIT

AN

D R

UN

OTHER INFORMATION:

LOCAL IDHT WT HAIR EYESDOBSEX RACE

NAME (LAST, FIRST, MIDDLE)

#UNIT DOBDRIVER LICENSE NUMBER STATE SEX RACE

ADDRESSPED

BIC

PRK

PRPVEHICLE OWNER

SAME

ACTION / ARREST / CITES

TO:

DRIVER TAKEN:

BY:

Y N UNKNOWN

EQUIPMENT:

NONE INSTLD

NO EQP USED LAP ONLY

SHLDR ONLYUNKNOWN

LAP / SHLDR

HELMET

CHLD RST-PRP

CHLD RST-IMPR

A/BAG-DEPLYD

A/BAG-NOT DP



ADDRESSPED

BIC

PRK

PRPVEHICLE OWNER

SAME


TO:

DRIVER TAKEN:

BY:

Y N UNKNOWN

EQUIPMENT:

NONE INSTLD


SHLDR ONLYUNKNOWN

LAP / SHLDR

HELMET

CHLD RST-PRP

CHLD RST-IMPR

A/BAG-DEPLYD

A/BAG-NOT DP

DISTRIBUTION

OFFICER NAME / NUMBER APPROVED BYAGENCYDATE

DOBSEX RACE

NPASSENGER TAKEN: YBY: TO:

UNKNOWN

#UNIT

DOBSEX RACE


UNKNOWN

#UNIT

DOBSEX RACE


UNKNOWN

#UNIT

ADDRESS

EJECTED EXTRCTD

EQUIPMENT

NONE INSTLD


SHLDR ONLYUNKNOWN

LAP / SHLDR

HELMET

CHLD RST-PRP

CHLD RST-IMPR

A/BAG-DEPLYD

A/BAG-NOT DP

PY N Y N

ADDRESS

EJECTED EXTRCTD

EQUIPMENT

NONE INSTLD


SHLDR ONLYUNKNOWN

LAP / SHLDR

HELMET

CHLD RST-PRP

CHLD RST-IMPR

A/BAG-DEPLYD

A/BAG-NOT DP

PY N Y N

ADDRESS

EJECTED EXTRCTD

EQUIPMENT

NONE INSTLD


SHLDR ONLYUNKNOWN

LAP / SHLDR

HELMET

CHLD RST-PRP

CHLD RST-IMPR

A/BAG-DEPLYD

A/BAG-NOT DP

PY N Y N

PASSENGER NAME

WITNESS

PASSENGER NAME

WITNESS

PASSENGER NAME

WITNESS

DAY OF WEEK

S SN

INSURANCE POLICY NUMBER

VEHICLE IDENTIFICATION NUMBER (VIN) COLOR

INSURANCE COMPANYNONE

FIREY N

EJECTED EXTRCTDY NPY N

STD SPD PST SPD

LICENSE PLATE NUMBER STATE YEAR MAKE




FIREY N


STD SPD PST SPD


LATITUDE LONGITUDE

PROPERTY DAMAGE

INJURY:NONE COMPLAINT

OF PAINVISIBLEINJURY

INCAPACITATED FATAL



INCAPACITATED FATAL

MODEL STYLE

MODEL STYLE

TO:

VEHICLE TOWED DUE TO VEHICLE DAMAGE

BY:UNKNOWNY N

TO:


BY:UNKNOWNNY

PUBLIC PROPERTY DAMAGE ESTIMATE:UNDER $2500OVER $2500

UNKNOWN HAZ. MATERIALS PHOTOS TAKEN TRAIN R/R TRUCK / BUS

PHONE:

)(WORKHOME CELL

PHONE:

)(WORKHOME CELL

( )WORKHOME CELLPHONE:

LOCATION OTHER:INJURY

VISIBLE INJURY

COMPLAINT OF PAIN

NONELFLR CR RRFATAL

INCAPACITATED


VISIBLE INJURY

COMPLAINT OF PAIN

NONELFLR CR RR

CF RFFATAL

INCAPACITATED


VISIBLE INJURY

COMPLAINT OF PAIN

NONELFLR CR RR

CF RFFATAL

INCAPACITATED

PHONE:

( )WORKHOME CELL

PHONE:

( )WORKHOME CELL

PHONE:

( )WORKHOME CELL

PHONE:

)(WORKHOME CELL

VEHICLE DAMAGE

USE ARROW TO SHOW FIRST IMPACT (SHADE IN DAMAGED AREA)

FRO

NT

MARK ALL THAT APPLY:

ROLLOVERUNDERCARTOTALEDUNKNOWN

DAMAGE ESTIMATENONEUNDER $2500OVER $2500

VEHICLE DAMAGE


FRO

NT




App

endi

x A

POLICE INCIDENT / CASE NUMBER EMS NOTIFIED EMS ARRIVALAMPM

AMPM

LOCAL CODES

AA BAA

PAGE OF

Check ONE box in all categories. Check ALL boxes that apply in categories with (★).

TRAFFIC CONTROL TYPE

NONESCHOOL BUS LIGHTSOFFICER / CROSSINGGUARD or FLAGGERTRAFFIC SIGNAL w/PEDESTRIAN CONTROLTRAFFIC SIGNALFLASHING BEACONSTOP SIGNYIELD SIGNRR CROSSING GATESRR CROSSING BUCKSRR FLASHING SIGNALRR CROSSING w/ PAVEMENT MARKINGSLANE CONTRLS / LINES/ STRIPES / DEVICESSCHOOL SIGNALOTHER REG SIGNTURN LANESUNKNOWN

OVERTURNFIRE / EXPLOSIONIMMERSIONGAS INHALATIONOTHER NON COLLISIONMEDICAL (Explain)

FIRST HARMFUL EVENT

NON COLLISION

# 1 # 2

ROAD CHARACTER# 1 # 2

STRAIGHT and LEVELSTRAIGHT w/ GRADECURVED and LEVELCURVED w/ GRADE

NUMBER OF LANES

SPECIAL ZONENONECONSTRUCTIONMAINTENANCE- ORS 811.230UTILITYSNOWSCHOOLUNKNOWN WORKOTHER

NON-INTERSECTIONINTERSECTIONINTERSECTION RELATEDDRIVEWAY ACCESSINTERCHANGE AREARAILROAD CROSSINGBRIDGETUNNELOTHER ON-ROAD AREA

SHOULDERTURNOUTROADSIDEBEYOND RIGHT OF WAYMEDIANDRIVEWAYPRIVATE DRIVERAILROAD CROSSINGOTHER OFF ROADPARKING LOTUNKNOWN

EVENT LOCATION

ON ROADWAY

OFF ROADWAY

COLLISION WITHPEDESTRIANPARKED MOTOR VEHICLERAILWAY TRAINBICYCLIST

CRASH TYPEHEAD ONREAR ENDANGLESIDESWIPEMANNER UNKNOWN

FIXED OBJECTBARRICADEBOULDER / ROCKBRIDGE O/PASS or RAILINGBUILDINGCULVERT HEADWALLCURBINGDITCHDIVIDER - CNCRT or STEELFENCE - NOT MEDIANFIRE HYDRANTHIGHWAY GUARDRAILHIGHWAY SIGNIMPACT ABSORBERLIGHT STANDARDMAILBOXOVERHEAD SIGN POSTOVERHEAD STRUCTUREPIER or COLUMNRETAINING WALLSIDESLOPE EARTHSIDESLOPE ROCK or STONETRAFFIC SIGNAL POSTTREEUNDERPASS TUNNELUTILITY POLEOTHER FIXED (Explain)

OTHER OBJECT (NOT FIXED)ANIMALTHROWN / FALLING OBJECTUNKNOWNOTHER OBJECT (Explain)

NUMBER OF LANES

ROAD FLOW

CLEARCLOUDY (OVERCAST)RAINSNOWSLEET / HAIL / ETCFOG / SMOGSMOKEBLOWING SAND / DIRTSEVERE CROSSWINDOTHER / UNKNOWN

WEATHER

VEH # 1 __

VEH # 2 __

PEDESTRIAN TYPENONEPEDESTRIANBICYCLISTCONVEYANCEWHEELCHAIRANIMAL RIDERRIDER of ANIM DRAWN VEHUNKNOWNOTHER (Explain)

TRUCK CONFIGURATION

TRUCK (2 or 3 AXLE)TRUCK / TRACTOR-SEMITRUCK and TRAILERDOUBLE TRAILERSTRIPLE TRAILERSDROMEDARY and SEMIHEAVY HAUL CONFIGBUSOTHER (Explain)

# 1 # 2

★ IMPAIRMENTDRIVER# 1 # 2

NONEUNDER INFL - DRUGSUNDER INFL - ALCOHOLUNDER INFL - MEDS

UNKNOWN

★ DRIVER FACTORS

NONECELL PHONE USEOBSTRUCTED VIEWFAILED TO YIELD ROWDISRGRD TRAF SIGNTOO FAST FOR CONDMADE IMPROPER TURNWRONG SIDE/WAYFOLLOW TOO CLOSELYIMPROPER LANE CHNGIMPROPER BACKINGIMPROPER PASSINGIMPROPER SIGNALIMPROPER PARKINGFATIGUE / DROWSYILL ___________________BLACKOUT____________

IMPROP RESTR EQP USEOTHER (Explain)

DRIVER# 1 # 2

NONEINSTRUCTION PERMITLICENSE RESTRICTIONEXPIRED LICENSEOUT OF CLASSSUSPNDED / REVOKEDUNLICENSED

DRIVER

DRIVER LICENSEVIOLATION

# 1 # 2

TRAFFIC CONTROLDEVICE CONDITION

NO MALFUNCTIONDOWN / MISSINGTURNED FROMPROPER POSITIONOBSCURED BY OTHER SIGNSOBSCURED BYPARKED VEHICLEOBSCURED BY VEGETATIONLIGHTS MALFUNCTIONLIGHTS STUCKGATES INOPERATIVEGATE ARM MISSINGOTHER RR MALFUNCTNOTHER IMPAIRMENTUNKNOWN

# 1 # 2

NONEBRAKESSTEERINGPOWER PLANTSUSPENSIONTIRESEXHAUSTLIGHTSSIGNALSWINDOWS / WINDSHLDRESTRAINT SYSTEMWHEELSCOUPLINGCARGOOTHER

★VEH RELATED FACTORS# 1 # 2

RESULTS OF TEST:

____%NO TEST GIVENTEST REFUSEDTESTED FOR DRUGSRESLTS NOT AVAILABLE

D 1 D 2 ____%

DETERMINED BY:INTOXILYZER TESTBLOOD OR URINE TESTFIELD SOB. TESTOBSERVED (SPEECH,ODOR, ETC.)DRE EVALUATIONSTATEMENTSUNKNOWNOTHER (Explain)

LIGHT

FULL DAYLIGHTDAWNDUSKDARK - LIGHTED WAYDARK - NOT LIGHTEDUNKNOWN

SURFACE CONDITION

DRYWETSNOW / SLUSHICYMUDDYDEBRISRUTS / HOLES / BUMPSWORN / POLISHEDLOW / SOFT SHOULDEROTHER (Explain)

# 1 # 2

SURFACE TYPE

CONCRETEBLACKTOP / ASPHALTGRAVELDIRTOTHER

# 1 # 2

__ TOTAL NUMBER OF LANES

TRAILER TYPE

LOG BUNKSEMITRAILERPOLE TRAILERFULL TRAILERMOBILE HOMEUTILITY TRAILERTRAVEL TRAILERBOAT TRAILERFARM EQUIPMENTHORSE TRAILERVEHICLE IN TOWOTHER / UNKNOWN

# 1 # 2

(NOT TO SCALE)

North

SKETCH & NARRATIVE

DISTANCE AFTER

UNIT 1

(FEET)

2

SKID MARKS TO (FEET)

# 1 # 2BACKINGSTOPPEDSTRAIGHT AHEADTURNING RIGHTTURNING LEFTMAKING U-TURNENTER TRAFFIC LANELEAVE TRAFFIC LANEOVERTAKINGCHANGING LANESAVOIDING MANEUVERMERGINGPARKINGNEGOTIATING A CURVEOTHER

VEHICLE MOVEMENT

NONEINTERFERED w/DRIVERUNDER INFL - DRUGSUNDER INFL - ALCOHOLUNKNOWN

OTHER (Explain)

★ PASSENGER FACTORSUNIT #1PASS

#1 #2

IN X-WALKNOT IN X-WALKNO X-WALK AVAILABLE

IN X-WALKNOT IN X-WALKNO X-WALK AVAILABLE

NOT IN ROADWAYSHOULDERMEDIANBIKE LANEUNKNOWN

PEDESTRIAN LOCATIONIN ROAD

INTERSECTION

OTHER

UNIT #2PASS#1 #2


OTHER (Explain)

★ PED / BIKE FACTORSNONEFAILED TO YIELD ROWDISREGARD TRAFFIC SIGNILLEGALLY IN ROADEQUIPMENT VIOLATIONCLOTHING NOT VISIBLEUNDER INFL - DRUGSUNDER INFL - ALCOHOL

UNKNOWNOTHER (Explain)

NO CONTRAST w/BKGRNDCONTRASTED w/BKGRNDREFLECTIVE

OTHER OTHER LIGHT SOURCEUNKNOWN

★ PEDESTRIAN ACTION

ENTER / CROSS ROADWALK / RIDE w/TRAFFWALK / RIDE AGAINSTSTEP ON / OFF VEHICLESTEP ON / OFF SCH BUSAPPRCH / LEAVE SC BUSAPPROACH / LEAVE VEHWORK / PUSHING VEHICLEOTHER WORKINGPLAYINGSTANDINGLYING DOWNUNKNOWN

PED / BIKE VISIBILITYCLOTHING

ONE WAY TRAFFICNOT PHYSLY DIVIDED

# 1 # 2

UNPAVEDBARRIERPAVEDCONT LEFT TURN

MEDIAN TYPE

Appendix A

CF RF

OREGON POLICE TRAFFIC CRASH REPORTDMVPOLICE INCIDENT / CASE NUMBER DMV FILE NUMBERCRASH DATE

M T W TH FCRASH TIME POLICE NOTIFIED POLICE ARRIVAL

AMPM

AMPM

AMPM


OF NEAREST INTERSECTING ROADWITHIN

NEAR

FEET

MILES

N S

E W

OF NEAREST CITY / TOWNWITHIN

NEAR

FEET

MILES

N S

E W

DMV CODECOUNTY MILE POST

PAGE OF

ADDRESS

SUSPECT NAME AKA IN CUSTODY NY

HIT

AN

D R

UN

OTHER INFORMATION:

LOCAL IDHT WT HAIR EYESDOBSEX RACE



ADDRESSPED

BIC

PRK

PRPVEHICLE OWNER

SAME


TO:

DRIVER TAKEN:

BY:

Y N UNKNOWN

EQUIPMENT:

NONE INSTLD


SHLDR ONLYUNKNOWN

LAP / SHLDR

HELMET

CHLD RST-PRP

CHLD RST-IMPR

A/BAG-DEPLYD

A/BAG-NOT DP



ADDRESSPED

BIC

PRK

PRPVEHICLE OWNER

SAME


TO:

DRIVER TAKEN:

BY:

Y N UNKNOWN

EQUIPMENT:

NONE INSTLD


SHLDR ONLYUNKNOWN

LAP / SHLDR

HELMET

CHLD RST-PRP

CHLD RST-IMPR

A/BAG-DEPLYD

A/BAG-NOT DP

DISTRIBUTION


DOBSEX RACE


UNKNOWN

#UNIT

DOBSEX RACE


UNKNOWN

#UNIT

DOBSEX RACE


UNKNOWN

#UNIT

ADDRESS

EJECTED EXTRCTD

EQUIPMENT

NONE INSTLD


SHLDR ONLYUNKNOWN

LAP / SHLDR

HELMET

CHLD RST-PRP

CHLD RST-IMPR

A/BAG-DEPLYD

A/BAG-NOT DP

PY N Y N

ADDRESS

EJECTED EXTRCTD

EQUIPMENT

NONE INSTLD


SHLDR ONLYUNKNOWN

LAP / SHLDR

HELMET

CHLD RST-PRP

CHLD RST-IMPR

A/BAG-DEPLYD

A/BAG-NOT DP

PY N Y N

ADDRESS

EJECTED EXTRCTD

EQUIPMENT

NONE INSTLD


SHLDR ONLYUNKNOWN

LAP / SHLDR

HELMET

CHLD RST-PRP

CHLD RST-IMPR

A/BAG-DEPLYD

A/BAG-NOT DP

PY N Y N

PASSENGER NAME

WITNESS

PASSENGER NAME

WITNESS

PASSENGER NAME

WITNESS

DAY OF WEEK

S SN




FIREY N


STD SPD PST SPD





FIREY N


STD SPD PST SPD


LATITUDE LONGITUDE

PROPERTY DAMAGE



INCAPACITATED FATAL



INCAPACITATED FATAL

MODEL STYLE

MODEL STYLE

TO:


BY:UNKNOWNY N

TO:


BY:UNKNOWNNY

PUBLIC PROPERTY DAMAGE ESTIMATE:UNDER $2500OVER $2500

UNKNOWN HAZ. MATERIALS PHOTOS TAKEN TRAIN R/R TRUCK / BUS

PHONE:

)(WORKHOME CELL

PHONE:

( )WORKHOME CELL

( )WORKHOME CELLPHONE:


VISIBLE INJURY

COMPLAINT OF PAIN

NONELFLR CR RRFATAL

INCAPACITATED


VISIBLE INJURY

COMPLAINT OF PAIN

NONELFLR CR RR

CF RFFATAL

INCAPACITATED


VISIBLE INJURY

COMPLAINT OF PAIN

NONELFLR CR RR

CF RFFATAL

INCAPACITATED

PHONE:

( )WORKHOME CELL

PHONE:

)(WORKHOME CELL

PHONE:

( )WORKHOME CELL

PHONE:

)(WORKHOME CELL

VEHICLE DAMAGE


FRO

NT




VEHICLE DAMAGE


FRO

NT




28

App

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x A

Accident Responsibilities & Information

This Form is for Informational Purposes Only

This form has been provided to you as a courtesy. Information on this form willhelp you complete your personal Accident Report Form for DMV.

Oregon law requires you to file an accident report with DMV within 72 hours if:

• There is injury or death resulting from the crash.

You must report an accident even if it happened on private property that ispremises open to the public, like a store parking lot.

You can get an Accident Report Form from your local law enforcement agency,your local DMV, and/or DMV website at www.oregondmv.com.

Failure to report an accident will result in the suspension of your driving privilege.This suspension will be effective for a period of 5 years, or until DMV receives areport, whichever is less. You may also be required to file proof of insurance for 3years.

Oregon law requires all motor vehicle owners to maintain liability insurancecoverage. DMV checks the insurance information on all accident reports. If DMVfinds you were uninsured at the time of the accident, or you fail to show proof ofinsurance on the Accident Report Form, DMV will suspend your driving privilegefor 1 year, and then you must file proof of insurance for 3 years after thesuspension.

Damage to the vehicle you were driving is over $2,500; Damage to the property other than a vehicle is over $2,500; Damage to any vehicle is greater than $2,500 and any vehicle is towed from the scene of the crash due to damage from the crash;

•••

29

Appendix B

735-46B ( - ) STK# 300025


DISTRIBUTION



ADDRESSPED

BIC

PRK

PRPVEHICLE OWNER

SAME


TO:

DRIVER TAKEN:

BY:

Y N UNKNOWN

EQUIPMENT:

NONE INSTLD


SHLDR ONLYUNKNOWN

LAP / SHLDR

HELMET

CHLD RST-PRP

CHLD RST-IMPR

A/BAG-DEPLYD

A/BAG-NOT DP




FIREY N


STD SPD PST SPD


TO:


BY:UNKNOWNNY

PHONE:

( )WORKHOME CELL

PHONE:

)(WORKHOME CELL

MODEL STYLE



INCAPACITATED

DOBSEX RACE


UNKNOWN

#UNIT

DOBSEX RACE


UNKNOWN

#UNIT

DOBSEX RACE


UNKNOWN

#UNIT

ADDRESS

EJECTED EXTRCTD

EQUIPMENT

NONE INSTLD


SHLDR ONLYUNKNOWN

LAP / SHLDR

HELMET

CHLD RST-PRP

CHLD RST-IMPR

A/BAG-DEPLYD

A/BAG-NOT DP

PY N Y N

ADDRESS

EJECTED EXTRCTD

EQUIPMENT

NONE INSTLD


SHLDR ONLYUNKNOWN

LAP / SHLDR

HELMET

CHLD RST-PRP

CHLD RST-IMPR

A/BAG-DEPLYD

A/BAG-NOT DP

PY N Y N

ADDRESS

EJECTED EXTRCTD

EQUIPMENT

NONE INSTLD


SHLDR ONLYUNKNOWN

LAP / SHLDR

HELMET

CHLD RST-PRP

CHLD RST-IMPR

A/BAG-DEPLYD

A/BAG-NOT DP

PY N Y N

PASSENGER NAME

WITNESS

PASSENGER NAME

WITNESS

PASSENGER NAME

WITNESS


VISIBLE INJURY

COMPLAINT OF PAIN

NONELFLR CR RR

CF RFINCAPACITATED


VISIBLE INJURY

COMPLAINT OF PAIN

NONELFLR CR RR

CF RFINCAPACITATED


VISIBLE INJURY

COMPLAINT OF PAIN

NONELFLR CR RR

CF RFINCAPACITATED

PHONE:

( )WORKHOME CELL

PHONE:

)(WORKHOME CELL

PHONE:

)(WORKHOME CELL

DOBSEX RACE


UNKNOWN

#UNIT ADDRESS

EJECTED EXTRCTD

EQUIPMENT

NONE INSTLD


SHLDR ONLYUNKNOWN

LAP / SHLDR

HELMET

CHLD RST-PRP

CHLD RST-IMPR

A/BAG-DEPLYD

A/BAG-NOT DP

PY N Y N

PASSENGER NAME

WITNESS


VISIBLE INJURY

COMPLAINT OF PAIN

NONELFLR CR RR

CF RFINCAPACITATEDPHONE:

)(WORKHOME CELL

DOBSEX RACE


UNKNOWN

#UNIT

DOBSEX RACE


UNKNOWN

#UNIT

ADDRESS

EJECTED EXTRCTD

EQUIPMENT

NONE INSTLD


SHLDR ONLYUNKNOWN

LAP / SHLDR

HELMET

CHLD RST-PRP

CHLD RST-IMPR

A/BAG-DEPLYD

A/BAG-NOT DP

PY N Y N

ADDRESS

EJECTED EXTRCTD

EQUIPMENT

NONE INSTLD


SHLDR ONLYUNKNOWN

LAP / SHLDR

HELMET

CHLD RST-PRP

CHLD RST-IMPR

A/BAG-DEPLYD

A/BAG-NOT DP

PY N Y N

PASSENGER NAME

WITNESS

PASSENGER NAME

WITNESS


VISIBLE INJURY

COMPLAINT OF PAIN

NONELFLR CR RR

CF RFINCAPACITATED


VISIBLE INJURY

COMPLAINT OF PAIN

NONELFLR CR RR

CF RFINCAPACITATED

PHONE:

( )WORKHOME CELL

PHONE:

( )WORKHOME CELL

DOBSEX RACE


UNKNOWN

#UNIT

DOBSEX RACE


UNKNOWN

#UNIT

ADDRESS

EJECTED EXTRCTD

EQUIPMENT

NONE INSTLD


SHLDR ONLYUNKNOWN

LAP / SHLDR

HELMET

CHLD RST-PRP

CHLD RST-IMPR

A/BAG-DEPLYD

A/BAG-NOT DP

PY N Y N

ADDRESS

EJECTED EXTRCTD

EQUIPMENT

NONE INSTLD


SHLDR ONLYUNKNOWN

LAP / SHLDR

HELMET

CHLD RST-PRP

CHLD RST-IMPR

A/BAG-DEPLYD

A/BAG-NOT DP

PY N Y N

PASSENGER NAME

WITNESS

PASSENGER NAME

WITNESS


VISIBLE INJURY

COMPLAINT OF PAIN

NONELFLR CR RR

CF RFINCAPACITATED


VISIBLE INJURY

COMPLAINT OF PAIN

NONELFLR CR RR

CF RFINCAPACITATED

PHONE:

)(WORKHOME CELL

PHONE:

)(WORKHOME CELL

OREGON POLICE TRAFFIC CRASH REPORT ADDITIONDMV PAGE OF

POLICE INCIDENT / CASE NUMBER CRASH DATE

COUNTY

VEHICLE DAMAGE


FRO

NT



DAMAGE ESTIMATENONEUNDER $ 500OVER $ 500

30

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x B POLICE INCIDENT / CASE NUMBER EMS NOTIFIED EMS ARRIVAL

AMPM

AMPM

LOCAL CODES

A BAAA

PAGE OF

Check ONE box in all categories. Check ALL boxes that apply in categories with (★).ROAD CHARACTER

# 3

NUMBER OF LANES

ROAD FLOW

VEH # 3 __

★ IMPAIRMENTDRIVER# 3

★ DRIVER FACTORSDRIVER# 3

DRIVER

DRIVER LICENSEVIOLATION

# 3

★VEH RELATED FACTORS# 3

RESULTS OF TEST:

D 1 ____%

DETERMINED BY:

__ TOTAL NUMBER OF LANES

TRAILER TYPE# 3

# 3VEHICLE MOVEMENT

# 3

MEDIAN TYPE

SURFACE CONDITION# 3

SURFACE TYPE# 3

TRAFFIC CONTROL TYPE# 3

TRAFFIC CONTROLDEVICE CONDITION

# 3

TRUCK CONFIGURATION# 3

★ PASSENGER FACTORSUNIT # 3PASS

#3

NO MALFUNCTIONDOWN / MISSINGTURNED FROMPROPER POSITIONOBSCURED BY OTHER SIGNSOBSCURED BYPARKED VEHICLEOBSCURED BY VEGETATIONLIGHTS MALFUNCTIONLIGHTS STUCKGATES INOPERATIVEGATE ARM MISSINGOTHER RR MALFUNCTNOTHER IMPAIRMENTUNKNOWN

NONESCHOOL BUS LIGHTSOFFICER / CROSSINGGUARD or FLAGGERTRAFFIC SIGNAL w/PEDESTRIAN CONTROLTRAFFIC SIGNALFLASHING BEACONSTOP SIGNYIELD SIGNRR CROSSING GATESRR CROSSING BUCKSRR FLASHING SIGNALRR CROSSING w/ PAVEMENT MARKINGSLANE CONTRLS / LINES/ STRIPES / DEVICESSCHOOL SIGNALOTHER REG SIGNTURN LANESUNKNOWN

CONCRETEBLACKTOP / ASPHALTGRAVELDIRTOTHER

DRYWETSNOW / SLUSHICYMUDDYDEBRISRUTS / HOLES / BUMPSWORN / POLISHEDLOW / SOFT SHOULDEROTHER (Explain)

STRAIGHT and LEVELSTRAIGHT w/ GRADECURVED and LEVELCURVED w/ GRADE

ONE WAY TRAFFICNOT PHYSLY DIVIDED

UNPAVEDBARRIERPAVEDCONT LEFT TURN

NONEINSTRUCTION PERMITLICENSE RESTRICTIONEXPIRED LICENSEOUT OF CLASSSUSPNDED / REVOKEDUNLICENSED

NONECELL PHONE USEOBSTRUCTED VIEWFAILED TO YIELD ROWDISRGRD TRAF SIGNTOO FAST FOR CONDMADE IMPROPER TURNWRONG SIDE/WAYFOLLOW TOO CLOSELYIMPROPER LANE CHNGIMPROPER BACKINGIMPROPER PASSINGIMPROPER SIGNALIMPROPER PARKINGFATIGUE / DROWSYILLBLACKOUT

UNKNOWN

OTHER (Explain)

NONEUNDER INFL - DRUGSUNDER INFL - ALCOHOLUNDER INFL - MEDS

UNKNOWN

INTOXILYZER TESTBLOOD OR URINE TESTFIELD SOB. TESTOBSERVED (SPEECH,ODOR, ETC.)DRE EVALUATIONSTATEMENTSUNKNOWNOTHER (Explain)

NO TEST GIVENTEST REFUSEDTESTED FOR DRUGSRESLTS NOT AVAILABLE


OTHER (Explain)

LOG BUNKSEMITRAILERPOLE TRAILERFULL TRAILERMOBILE HOMEUTILITY TRAILERTRAVEL TRAILERBOAT TRAILERFARM EQUIPMENTHORSE TRAILERVEHICLE IN TOWOTHER / UNKNOWN

TRUCK (2 or 3 AXLE)TRUCK / TRACTOR-SEMITRUCK and TRAILERDOUBLE TRAILERSTRIPLE TRAILERSDROMEDARY and SEMIHEAVY HAUL CONFIGBUSOTHER (Explain)

BACKINGSTOPPEDSTRAIGHT AHEADTURNING RIGHTTURNING LEFTMAKING U-TURNENTER TRAFFIC LANELEAVE TRAFFIC LANEOVERTAKINGCHANGING LANESAVOIDING MANEUVERMERGINGPARKINGNEGOTIATING A CURVEOTHER

NONEBRAKESSTEERINGPOWER PLANTSUSPENSIONTIRESEXHAUSTLIGHTSSIGNALSWINDOWS / WINDSHLDRESTRAINT SYSTEMWHEELSCOUPLINGCARGOOTHER

31

Appendix C

18)

735-47 ( -17) STK # 300570

Page ____ of ____

POLICE TRUCK / BUS / HAZMAT CRASH SUPPLEMENTAL*Complete this form if one or more qualifying vehicles was involved. Check at least one box in Category 1 and 2 listed below.

* FAX only this Supplemental report to ODOT Crash Analysis Reporting Unit at (503) 986-4249 within 24 hours.

SEQUENCE OF EVENTS (for this vehicle)VEHICLE INFORMATION

VEHICLE CONFIGURATION

1

SelectAppropriate

2

3

4

5

6a

7

8

9

10a*

11a

Triples (tractor with 3 trailers)

Triples (truck with 2 trailers)

Doubles (any)

Straight Truck-Full Trailer

Standard Tractor/Semi Trailer

Single Truck

Bobtail

Saddlemount

Heavy Haul

Cargo Body Type (circle appropriate type):Van, Flatbed, Tank, Dump, Belly-Dump, Pole, Garbage, Drop-Box, Auto Carrier, Livestock, Chip, Low-Boy, Mobile Home Toter, Utility, Container, Bulk-Hopper, Fixed Load, Concrete Mixer, Intermodal Chassis, Other: ___________________

VEHICLE DAMAGEUse arrow to show first impact (shade in damaged area).

OFFICER NAME / NUMBER DATE

FALSE LOG

NO LOG BOOK

DRIVER LOG NOT CURRENT

60/70 HOUR RULE VIOLATION

10 HOUR RULE VIOLATION

15 HOUR RULE VIOLATION

CURRENT AND PREVIOUS DAYS LOG NOT IN POSSESSION

FAILURE TO RETAIN 7 PREVIOUS DAYS LOG

DRIVER HOURS RECAPFor Certified Inspectors

DATE HOURS ON DUTY

DRIVER INFORMATION

CO-DRIVER INFORMATION

AGENCY APPROVED BY

11 21 2111CROSS MEDIAN / CENTERLINENON-COLLISION: EQUIP-MENT FAILURE (TIRE, ETC.)COLLISION INVOLVINGWORK ZONE MAINT. EQUIP.RAN OFF ROAD

JACKKNIFE / SKID

OVERTURN

DOWNHILL RUNAWAY

CARGO LOSS OR SHIFT

EXPLOSION OR FIRE

SEPARATION OF UNITS

CRASH INVOLVINGPEDESTRIAN

CRASH INVOLVING MOTORVEHICLE IN TRANSPORTCRASH INVOLVING PARKEDMOTOR VEHICLE

CRASH INVOLVING TRAIN

CRASH INVOLVINGPEDAL CYCLE

CRASH INVOLVING ANIMAL

CRASH INVOLVING FIXEDOBJECTCRASH INVOLVING OTHEROBJECT

NON-COLLISION: OTHER

COLLISION WITH UNKNOWNMOVABLE OBJECT

OTHER

FATAL INJURY VEHICLE TOWEDCATEGORY 1 CATEGORY 29 OR MORE SEATSINCLUDING DRIVER

10,001 LBS OR MORE(GVWR or GCWR)

ANY VEHICLE DISPLAYINGHAZARDOUS MATERIAL PLACARD

POLICE INCIDENT / CASE NUMBER CRASH DATE DAY OF WEEKM T W TH F

S SN

CRASH TIMEAMPM


BRIEF NARRATIVE:

BASE PLATE NUMBERSTATE

OR DOT PLATE NUMBER

GROSS VEHICLE WEIGHT RATING or GROSS COMBINATION WEIGHT RATING10,000 LBS or LESS

10,001 LBS to 26,000 LBS

GREATER THAN 26,000 LBS

Did vehicle have a HAZARDOUS MATERIAL placard?

If "Yes," enter name or 4 digit number fromplacard diamond or box (CODE #32)

Enter 1 Digit Number from bottom of diamond:

Was hazardous material (cargo) released from this vehicle?

Was inspection done on this vehicle?

Inspection Number _____________________________ Level: 1, 2, 3, 4

1. Yes 2. No

1. Yes 2. No

1. Yes 2. No

NAME

ADDRESS (Street or PO Box Number)

CITY

STATE ZIP CODE

PLATE NUMBER

US DOT

IDENTIFICATION NUMBERS None = 0

NAME (Last, First, Middle)

DRIVER LICENSE # STATE CLASS ENDORSEMENT

NAME (Last, First, Middle)

DRIVER LICENSE # STATE CLASS ENDORSEMENT

MC / MX

➠

TOTAL

FRONT

DUE TO DAMAGE

CARRIER INFORMATIONMARK ALL THAT APPLY:

INTERSTATE

INTRASTATE

NOT IN COMMERCE - GOVERNMENT (TRUCKS / BUSES)

NOT IN COMMERCE - OTHER (OVER 10,000 LBS)

6b

10b*BUS (9 or more seatsincluding driver)

BUS (16 or more seatsincluding driver)

PASSENGER (displaying HM Placard)

11b

LIGHT TRUCK (displaying HM Placard)

*BUS USE (circle one): School, Transit,

TWO AXLE THREE AXLE

10c*

NOT A BUS (Less than

driver.)

9 seats including driver.Personal use van with 9or more seats including

Intercity, Charter, Other: ______________

32

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x C

Oregon Police Traffic Crash Report and Police …...7 Conversion Table for Feet to Miles: Miles Hundredths Feet Miles Hundredths Feet Miles Hundredths Feet Miles Hundredths Feet Miles

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