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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|Q1 |
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|R1 |
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|R2 |
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|G |
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|T1 |
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|T2 |
| |
|T3 |
| |
|T4 |
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