STATE OF VERMONT UNIFORM CRASH REPORT



INSTRUCTIONS FOR COMPLETING THE VERMONT UNIFORM CRASH REPORT | |

|Instructions for completing the Uniform Crash Report may be found in the Investigator’s Guide for Completing the Uniform Crash Report at the Agency of |

|Transportation web site. |

|Each form provides space for the reporting of information relative to two vehicles or a vehicle and a pedestrian. |

|Each form also provides space for the reporting of information relative to seven involved persons. |

|Whenever the number of vehicles or involved persons exceeds the space available on the form, additional forms must be utilized. |

|When using additional forms, the third, fourth and fifth vehicles being reported will always be reported as Vehicles #3, #4 and #5 respectively. The |

|preprinted Vehicle 1 and Vehicle 2 should be crossed out and the correct vehicle number substituted accordingly. |

|Use United States Postal Service Standard State abbreviations when entering such information. |

|Use the following data entry sequence during the crash investigation: |

|Complete Page 1 (face page of the report) |

|Use Overlay 1 to enter data into unshaded boxes. |

|Use Overlay 2 to enter data into shaded boxes, complete relevant sections. |

|Complete Page 3, relevant sections. |

|Complete crash narrative on Page 2, if necessary. |

|Complete crash diagram on Page 4, if necessary. |

|Be sure to provide each operator with a colored copy of Page 1 of the crash report. |

|Be sure that overlay arrows are correctly aligned with the shaded and unshaded boxes on Page 1 of the crash form. |

|INSTRUCTIONS FOR COMMERCIAL VEHICLES |

|GENERAL INSTRUCTIONS |

|Complete relevant Commercial Vehicle sections of the form when the crash involves: |

|Any truck having a gross vehicle weight rating (GVWR) of more than 10,000 pounds or a gross combination weight rating (GCWR) over 10,000 pounds used on |

|public highways; |

|OR |

|Any motor vehicle designed to transport more than eight people, including the driver; |

|OR |

|Any vehicle displaying a hazardous materials placard (regardless of weight). |

|AND |

|Complete relevant Commercial Vehicle sections of the form when the crash involves a vehicle as listed above and results in any of the following: |

|One or more fatalities (including person(s) who die within 30 days of the crash); |

|OR |

|One or more persons injured and transported from the scene for immediate medical attention; |

|OR |

|One or more motor vehicles were disabled as a result of the crash and transported away from the scene by a two truck or other vehicle. |

| |

|Crashes involving local, state and federal government owned vehicles should be reported as commercial vehicle crashes. Rented or leased commercial |

|vehicles that meet any of the above vehicle types must also be reported as commercial motor vehicles. |

|RELEVANT SECTIONS OF THE FORM |

|If “Comm Veh” box has been checked in the “Vehicle” section(s) of Page 1, then Complete Overlay 2: Commercial Vehicle Only” section, boxes R.S. & T, |

|then Complete page 3: “Commercial Vehicle” section. |

|PLATE TYPES |

|A. Autos |F. Handicapped Dealer Plates |K. VT state government - auto, truck |

|B. Trucks |G. ATV, Moped, Motorcycle |L. Out of state - Auto |

|C. Trailers |H. Special - Unspecified |M. Out of state - Truck |

|D. Farm Trucks |I. Bus |N. Out of state - Other |

|E. Moveable Dealer Plates |J. Municipal: Auto, Truck, Bus | |

|STATE OF VERMONT UNIFORM CRASH REPORT |

|Incident Number |Reporting Agency |Date |Time |

|      |      |      |      |

|City/Town |Street Address |TH#       VT#       US#       I-      |

|      |      | |

|Intersection with       OR |Operator Report Required | |

|Nearest Intersecting St. or Landmark       |Y N | |

| | |Mile Marker |

|Distance (from nearest Int. St) |Direction (from nearest Int. St.) |Coordinates |    |    |    |    |

| |N S E W | | | | | |

|      Feet       Miles | |Lat. |      |    |    |    |    |

|Posted Speed       | |Long. |      |    |    |    |    |

|O |VEHICLE #1 Name: Last |First |M.I. |License |State |Class |

|P |      |      |      |      |      |      |

|E | | | | | | |

|R | | | | | | |

|A | | | | | | |

|T | | | | | | |

|O | | | | | | |

|R | | | | | | |

| |Address |      |City/Town |State |Zip |

| | | |      |      |      |

| |Telephone |DOB |Sex | Restrictions |Unoccupied |Seat Belt |CDL |

| |      |      | |      |Y N |Y N |Y N |

|O | Same as Operator |Name: |      |First |M.I. |

|W | |Last | |      |      |

|N | | | | | |

|E | | | | | |

|R | | | | | |

| |Address |City/Town |State |Zip |Tel. |

| |      |      |      |      |      |

| |Insurance Co. |Policy No. |

| |      |      |

|VEH|Registration No. |Plate Type |VIN |

|ICL|      |      |                                                   |

|E | | | |

| |Vehicle Yr |State |[pic] |9 Hood |Est. Speed |Comm Vehicle |

| |      |      | |10 Roof |      |Y N |

| | | | |11 Trunk | | |

| | | | |12 Undercarriage |Direction of Travel |If yes, see |

| | | | |13 Total |N S E W |overlay 2 and page|

| | | | | | |3 |

| |Make |Model | | | | |

| |      |      | | | | |

| |Towed By | | | | |

| |      | | | | |

|O |VEHICLE #2 Name: Last |First |M.I. |License |State |Class |

|P |      |      |      |      |      |      |

|E | | | | | | |

|R | | | | | | |

|A | | | | | | |

|T | | | | | | |

|O | | | | | | |

|R | | | | | | |

| |Address |      |City/Town |State |Zip |

| | | |      |      |      |

| |Telephone |DOB |Sex | Restrictions |Unoccupied |Seat Belt |CDL |

| |      |      | |      |Y N |Y N |Y N |

|O | Same as Operator |Name: |      |First |M.I. |

|W | |Last | |      |      |

|N | | | | | |

|E | | | | | |

|R | | | | | |

| |Address |City/Town |State |Zip |Tel. |

| |      |      |      |      |      |

| |Insurance Co. |Policy No. |

| |      |      |

|VEH|Registration No. |Plate Type |VIN |

|ICL|      |      |                                                   |

|E | | | |

| |Vehicle Yr |State |[pic] |9 Hood |Est. Speed |Comm Vehicle |

| |      |      | |10 Roof |      |Y N |

| | | | |11 Trunk | | |

| | | | |12 Undercarriage |Direction of Travel |If yes, see |

| | | | |13 Total |N S E W |overlay 2 and page|

| | | | | | |3 |

| |Make |Model | | | | |

| |      |      | | | | |

| |Towed By | | | | |

| |      | | | | |

|Non-Vehicle Property Damage | | |

|Owner |Address |Phone |

|      |      |      |

|Damage Description |

|      |

|Other Persons and Witnesses Involved (For investigated crashes see page 3.) |

|Name |Address |Phone |

|      |      |      |

|      |      |      |

|      |      |      |

|Reporting Officer |Date |Approved |Date |

|      |      |      |      |

*Operators involved in a crash which results in injury, death, or total property damage equal to $1,000 or more, must file a report with DMV.

|Crash Narrative |Incident Number       |

| |Reporting Agency       |

|      |

Officer’s Signature       Additional Sheets Attached Y N

|Vehicle Number       |Commercial Vehicle |Incident #       |

|Carrier’s Identification Numbers |

|US DOT |ICC MC | Interstate Carrier |State Name |State # |

|      |      | |      |      |

|Carrier’s Name |

|      |

|Carrier’s Address |City |State |Zip |

|      |      |      |      |

|Source (check all that apply): Vehicle Side Shipping Papers Driver Carrier |

|Vehicle Information |

|Axles on Vehicle (including trailers)       |Gross Vehicle Weight Rating       lbs or       kg |

|Length of Vehicle (including trailer)       ft or       meters |Length of Trailer       ft or       meters |

|Trailer License Number       State       |Trailer Identification Number       |

|Hazardous Material |Non-Commercial Trailer |

|Name or 4 Digit Number | |

|Placard Spill         from Diamond or Box | |

| | |

|      Small number from bottom | |

| |Vehicle 1 |

| |Year |Make |Model |Plate # |State |

| |      |      |      |      |      |

| |Vehicle 2 |

| |Year |Make |Model |Plate # |State |

| |      |      |      |      |      |

|Additional Operator Information |

|Alcohol Test |Vehicle 1    |Drug Test | |Drug Test Result | |

|1. Not Given | |1. None Given |Veh 1    |1. Marijuana |Veh 1       |

|2. Refused |Test Result 0.     BAC |2. Refused | |2. Cocaine | |

|3. Blood/Serum | |3. Blood/Serum | |3. Opiate | |

|4. Urine |Vehicle 2    |4. Urine |Veh 2    |4. Amphetamine |Veh 2       |

|5. Other | |5. Other | |5. PCP | |

|6. Breath Preliminary |Test Result 0.     BAC | | |6. Other | |

|7. Breath Evidentiary | | | | | |

| | | | | | |

|Citations Issued - Vehicle 1 |Citations Issued - Vehicle 2 |

|Ticket # |      |Violation Code |      |Ticket # |      |Violation Code |      |

| |      | |      | |      | |      |

| |      | |      | |      | |      |

|EMS Run number       |EMS Agency       |Destination Hospital       |

|Operators, Occupants, Pedestrians, Cyclists – Excluding Witnesses |

|Name |

|Type |Seat Location |11 |Injury |Restraint |Ejected |Airbag Deployed: |

|1. Operator | | |1. Fatal |0. Unknown |1. Not Ejected |1. Yes |

|2. Occupant |1 |12 |2. Injury - Incapacitating|1. None Used |2. Totally Ejected|2. No |

|3. Pedestrian |2 | |3. Injury - |2. Shoulder Belt Only |3. Partially |3. Unknown |

|4. Bicyclist |3 | |Non-incapacitating |3. Lap Belt Only |Ejected | |

|5. Unknown | | |4. Possible Injury |4. Shoulder and Lap Belt |4. Not applicable |Extracted |

| |4 | |5. No Injury |5. Child Safety Seat Used |5. Unknown |1. Yes |

| |5 | |6. Unknown |6. Helmet Used – Eye | |2. No |

| |6 | | |Protection | | |

| | | | |7. Helmet Used - No Eye Prot.| | |

| |7 | | |8. Not Reported | | |

| |8 | | | | | |

| |9 | | | | | |

| | | | | | | |

| |10 | | | | | |

| | | | | | | |

|Pedestrian/Cyclist Codes on Overlay 1 |

Crash Diagram Incident Number      

Vehicle Moved Y N

[pic]

Additional Sheets Attached Y N

[pic]

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|P1 |

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|R1 |

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|T1 |

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|T2 |

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|T3 |

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|T4 |

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