DMV OREGON POLICE TRAFFIC CRASH REPORT PAGE OF

DM V OREGON POLICE TRAFFIC CRASH REPORT

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PAGE

OF

POLICE INCIDENT / CASE NUMBER CRASH DATE

DAY OF WEEK M T W TH F

S SN

COUNTY

ROAD ON WHICH CRASH OCCURRED

CRASH TIME

POLICE NOTIFIED

POLICE ARRIVAL

DMV FILE NUMBER

AM

AM

AM

PM

PM

PM

LATITUDE

LONGITUDE

MILE POST

DMV CODE

WITHIN NEAR

FEET N S OF NEAREST INTERSECTING ROAD MILES E W

PROPERTY DAMAGE

PUBLIC PROPERTY DAMAGE ESTIMATE:

UNIT NAME (LAST, FIRST, MIDDLE)

#

UNDER $500 OVER $500

WITHIN NEAR

FEET N S OF NEAREST CITY / TOWN MILES E W

UNKNOWN

HAZ. MATERIALS

DRIVER LICENSE NUMBER

PHOTOS TAKEN

TRAIN R/R

STATE SEX RACE

DOB

TRUCK / BUS

PED ADDRESS

BIC

PRK VEHICLE OWNER

PRP

SAME

FIRE STD SPD PST SPD YN

INSURANCE COMPANY NONE

INSURANCE POLICY NUMBER

PHONE: HOME WORK CELL

(

)

PHONE: HOME WORK CELL

(

)

EJECTED EXTRCTD VEHICLE IDENTIFICATION NUMBER (VIN) YPN Y N

LICENSE PLATE NUMBER STATE YEAR MAKE

MODEL

STYLE

COLOR

FRONT

VEHICLE TOWED DUE TO VEHICLE DAMAGE Y BY: VEHICLE DAMAGE

N

UNKNOWN

TO:

MARK ALL THAT APPLY:

DAMAGE ESTIMATE ROLLOVER

NONE

UNDERCAR

UNDER $500

TOTALED

OVER $500

UNKNOWN

DRIVER TAKEN: Y N BY:

UNKNOWN TO:

INJURY: ./!00!2%.4

EQUIPMENT:

0/33)",%

3530%#4%$ -)./2

NO EQP USED LAP ONLY

LAP / SHLDR

3530%#4%$ 3%2)/53

CHLD RST-PRP

NONE INSTLD UNKNOWN ACTION / ARREST / CITES

SHLDR ONLY HELMET

CHLD RST-IMPR

&!4!, A/BAG-DEPLYD A/BAG-NOT DP

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

AKA

IN CUSTODY YN

ADDRESS

OTHER INFORMATION:

SEX RACE DOB

HT

WT

HAIR

EYES

LOCAL ID

HIT AND RUN

UNIT NAME (LAST, FIRST, MIDDLE)

#

DRIVER LICENSE NUMBER

STATE SEX RACE

DOB

PED ADDRESS

BIC

PRK VEHICLE OWNER

PRP

SAME

FIRE STD SPD PST SPD YN

INSURANCE COMPANY NONE

INSURANCE POLICY NUMBER

PHONE: HOME WORK CELL

(

)

PHONE: HOME WORK CELL

(

)

EJECTED EXTRCTD VEHICLE IDENTIFICATION NUMBER (VIN) YPN Y N

LICENSE PLATE NUMBER STATE YEAR MAKE

MODEL

STYLE

COLOR

VEHICLE TOWED DUE TO VEHICLE DAMAGE Y N

UNKNOWN

BY:

TO:

FRONT

VEHICLE DAMAGE

MARK ALL THAT APPLY:

DAMAGE ESTIMATE ROLLOVER

NONE

UNDERCAR

UNDER $500

TOTALED

OVER $500

UNKNOWN

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

UNIT

#

PASSENGER NAME WITNESS

SEX RACE DOB

PHONE:

(

HOME

)

WORK

CELL

PASSENGER TAKEN: Y N BY:

UNKNOWN TO:

UNIT

#

SEX

PASSENGER NAME WITNESS RACE DOB

PHONE: HOME WORK CELL

(

)

PASSENGER TAKEN: Y N BY:

UNKNOWN TO:

UNIT

#

SEX

PASSENGER NAME WITNESS RACE DOB

PHONE: HOME WORK CELL

(

)

PASSENGER TAKEN: Y N BY:

UNKNOWN TO:

DRIVER TAKEN: Y N BY:

UNKNOWN TO:

INJURY: ./!00!2%.4

0/33)",%

3530%#4%$ -)./2

EQUIPMENT:

NO EQP USED LAP ONLY

LAP / SHLDR

NONE INSTLD UNKNOWN

SHLDR ONLY HELMET

ACTION / ARREST / CITES

3530%#4%$ 3%2)/53

CHLD RST-PRP

CHLD RST-IMPR

&!4!, A/BAG-DEPLYD A/BAG-NOT DP

ADDRESS

INJURY ./!00!2%.4

0/33)",%

3530-)./2 35303%2)/53

&!4!,

EQUIPMENT

NO EQP USED LAP ONLY

NONE INSTLD UNKNOWN

SHLDR ONLY

ADDRESS

LOCATION

OTHER:

LF CF RF

LR CR RR

EJECTED EXTRCTD YPN Y N

LAP / SHLDR CHLD RST-PRP A/BAG-DEPLYD

HELMET

CHLD RST-IMPR A/BAG-NOT DP

INJURY ./!00!2%.4

0/33)",%

3530-)./2 35303%2)/53

&!4!,

EQUIPMENT

NO EQP USED LAP ONLY

NONE INSTLD UNKNOWN

SHLDR ONLY

ADDRESS

LOCATION

OTHER:

LF CF RF

LR CR RR

EJECTED EXTRCTD YPN Y N

LAP / SHLDR CHLD RST-PRP A/BAG-DEPLYD

HELMET

CHLD RST-IMPR A/BAG-NOT DP

INJURY ./!00!2%.4

0/33)",%

3530-)./2 35303%2)/53

&!4!,

EQUIPMENT

NO EQP USED LAP ONLY

NONE INSTLD UNKNOWN

SHLDR ONLY

LOCATION

OTHER:

LF CF RF

LR CR RR

EJECTED EXTRCTD YPN Y N

LAP / SHLDR CHLD RST-PRP A/BAG-DEPLYD

HELMET

CHLD RST-IMPR A/BAG-NOT DP

DISTRIBUTION

OFFICER NAME / NUMBER

DATE

AGENCY

APPROVED BY

A22

STK# 300018

POLICE INCIDENT / CASE NUMBER EMS NOTIFIED AM EMS ARRIVAL

AM LOCAL CODES

PAGE

OF

PM

PM

A

B

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

FIRST HARMFUL EVENT

WEATHER

ROAD CHARACTER VEH RELATED FACTORS TRUCK CONFIGURATION

PEDESTRIAN TYPE

NON COLLISION

OVERTURN FIRE / EXPLOSION IMMERSION GAS INHALATION OTHER NON COLLISION MEDICAL (Explain)

CLEAR CLOUDY (OVERCAST) RAIN SNOW SLEET / HAIL / ETC FOG / SMOG SMOKE

#1 #2

#1 #2

STRAIGHT and LEVEL

NONE

STRAIGHT w/ GRADE

BRAKES

CURVED and LEVEL

STEERING

CURVED w/ GRADE

POWER PLANT

VEH # 1 __ NUMBER OF LANES

SUSPENSION TIRES

#1 #2

TRUCK (2 or 3 AXLE) TRUCK / TRACTOR-SEMI TRUCK and TRAILER DOUBLE TRAILERS TRIPLE TRAILERS DROMEDARY and SEMI

NONE PEDESTRIAN BICYCLIST CONVEYANCE WHEELCHAIR ANIMAL RIDER RIDER of ANIM DRAWN VEH

COLLISION WITH

BLOWING SAND / DIRT SEVERE CROSSWIND

VEH # 2 __ NUMBER OF LANES

EXHAUST LIGHTS

HEAVY HAUL CONFIG BUS

UNKNOWN OTHER (Explain)

PEDESTRIAN PARKED MOTOR VEHICLE

OTHER / UNKNOWN

__TOTAL NUMBER OF LANES

SIGNALS WINDOWS / WINDSHLD

OTHER (Explain)

PEDESTRIAN ACTION

RAILWAY TRAIN

BICYCLIST

CRASH TYPE

HEAD ON REAR END ANGLE SIDESWIPE SECONDARY CRASH LANE SPLITTING MANNER UNKNOWN FIXED OBJECT

BARRICADE

BOULDER / ROCK

SURFACE CONDITION

ROAD FLOW

#1 #2 DRY WET SNOW / SLUSH

#1 #2 ONE WAY TRAFFIC NOT PHYSLY DIVIDED

ICY

MEDIAN TYPE

MUDDY

UNPAVED

DEBRIS

BARRIER

RUTS / HOLES / BUMPS

PAVED

WORN / POLISHED

CONT LEFT TURN

LOW / SOFT SHOULDER OTHER (Explain)

DRIVER LICENSE STATUS

BRIDGE O/PASS or RAILING BUILDING

SURFACE TYPE

DRIVER #1 #2

CULVERT HEADWALL CURBING DITCH DIVIDER - CNCRT or STEEL FENCE - NOT MEDIAN FIRE HYDRANT HIGHWAY GUARDRAIL

#1 #2 CONCRETE BLACKTOP / ASPHALT GRAVEL DIRT OTHER

VALID INSTRUCTION PERMIT VIOL RESTRICTION EXPIRED LICENSE OUT OF CLASS SUSPNDED / REVOKED UNLICENSED

RESTRAINT SYSTEM WHEELS COUPLING CARGO OTHER

PASSENGER FACTORS

PASS UNIT #1

#1 #2 NONE INTERFERED w/DRIVER

ENTER / CROSS ROAD WALK / RIDE w/TRAFF WALK / RIDE AGAINST STEP ON / OFF VEHICLE STEP ON / OFF SCH BUS

VEHICLE MOVEMENT

UNDER INFL - DRUGS UNDER INFL - ALCOHOL

APPRCH / LEAVE SC BUS APPROACH / LEAVE VEH

#1 #2

UNKNOWN

WORK / PUSHING VEHICLE

BACKING STOPPED

)-02/02%342%1053% OTHER (Explain)

OTHER WORKING PLAYING

STRAIGHT AHEAD

STANDING

TURNING RIGHT TURNING LEFT MAKING U-TURN

PASS UNIT #2

#1 #2 NONE

LYING DOWN UNKNOWN

PED / BIKE VISIBILITY

ENTER TRAFFIC LANE LEAVE TRAFFIC LANE OVERTAKING CHANGING LANES AVOIDING MANEUVER MERGING PARKING NEGOTIATING A CURVE

INTERFERED w/DRIVER CLOTHING

UNDER INFL - DRUGS

NO CONTRAST w/BKGRND

UNDER INFL - ALCOHOL

CONTRASTED w/BKGRND

UNKNOWN

REFLECTIVE

)-02/0 2%342 %10 53% OTHER

OTHER (Explain)

OTHER LIGHT SOURCE

UNKNOWN

HIGHWAY SIGN IMPACT ABSORBER

LIGHT

LIGHT STANDARD

FULL DAYLIGHT

MAILBOX

DAWN

OVERHEAD SIGN POST

DUSK

OVERHEAD STRUCTURE

DARK - LIGHTED WAY

PIER or COLUMN

DARK - NOT LIGHTED

RETAINING WALL

UNKNOWN

SIDESLOPE EARTH

SIDESLOPE ROCK or STONE

TRAFFIC SIGNAL POST

TRAFFIC CONTROL TYPE

TREE

#1 #2

UNDERPASS TUNNEL

NONE

UTILITY POLE

SCHOOL BUS LIGHTS

OTHER FIXED (Explain)

OFFICER / CROSSING

GUARD or FLAGGER

OTHER OBJECT (NOT FIXED)

TRAFFIC SIGNAL w/

DRIVER FACTORS

DRIVER #1 #2

NONE CELL PHONE USE OBSTRUCTED VIEW FAILED TO YIELD ROW DISRGRD TRAF SIGN TOO FAST FOR COND MADE IMPROPER TURN WRONG SIDE/WAY FOLLOW TOO CLOSELY IMPROPER LANE CHNG IMPROPER BACKING IMPROPER PASSING IMPROPER SIGNAL IMPROPER PARKING

# 1

OTHER

TRAILER TYPE # 2

LOG BUNK SEMITRAILER POLE TRAILER FULL TRAILER MOBILE HOME UTILITY TRAILER TRAVEL TRAILER BOAT TRAILER FARM EQUIPMENT HORSE TRAILER VEHICLE IN TOW OTHER / UNKNOWN

PEDESTRIAN LOCATION

IN ROAD

IN X-WALK NOT IN X-WALK NO X-WALK AVAILABLE INTERSECTION IN X-WALK NOT IN X-WALK NO X-WALK AVAILABLE OTHER NOT IN ROADWAY SHOULDER MEDIAN BIKE LANE UNKNOWN

PED / BIKE FACTORS NONE FAILED TO YIELD ROW DISREGARD TRAFFIC SIGN ILLEGALLY IN ROAD EQUIPMENT VIOLATION CLOTHING NOT VISIBLE UNDER INFL - DRUGS UNDER INFL - ALCOHOL ).!44%.4)6% $)342!#4%$ #%,, 0(/.% UNKNOWN OTHER (Explain)

ANIMAL THROWN / FALLING OBJECT UNKNOWN OTHER OBJECT (Explain)

EVENT LOCATION ON ROADWAY

NON-INTERSECTION

PEDESTRIAN CONTROL TRAFFIC SIGNAL FLASHING BEACON STOP SIGN YIELD SIGN RR CROSSING GATES RR CROSSING BUCKS RR FLASHING SIGNAL RR CROSSING w/

FATIGUE / DROWSY

L ILL??????????????????

BLACKOUT???????????

SKETCH & NARRATIVE UNIT

1

).!44%.4)6%

North

SKID MARKS TO

(FEET)

$)342!#4%$

5.+./7.

(NOT TO SCALE)

DISTANCE AFTER

(FEET)

)-02/02%342%1053%

/4(%2%XPLAIN

2

INTERSECTION

PAVEMENT MARKINGS

INTERSECTION RELATED DRIVEWAY ACCESS INTERCHANGE AREA RAILROAD CROSSING BRIDGE TUNNEL OTHER ON-ROAD AREA OFF ROADWAY

SHOULDER TURNOUT ROADSIDE BEYOND RIGHT OF WAY MEDIAN DRIVEWAY PRIVATE DRIVE RAILROAD CROSSING OTHER OFF ROAD PARKING LOT UNKNOWN

SPECIAL ZONE

NONE

LANE CONTROLS/LINES/

IMPAIRMENT

STRIPES/ DEVICES SCHOOL SIGNAL

DRIVER #1 #2

OTHER REG SIGN TURN LANES

NONE UNDER INFL - DRUGS

UNKNOWN

UNDER INFL - ALCOHOL

UNDER INFL - MEDS

TRAFFIC CONTROL DEVICE CONDITION

5.$%2 ).&, -!2)*5!.! UNDER INFL-PSILOCYBIN

#1 #2

UNKNOWN

NO MALFUNCTION DOWN / MISSING TURNED FROM PROPER POSITION OBSCURED BY OTHER SIGNS OBSCURED BY PARKED VEHICLE OBSCURED BY VEGETATION LIGHTS MALFUNCTION

DETERMINED BY:

INTOXILYZER TEST BLOOD OR URINE TEST FIELD SOB. TEST OBSERVED (SPEECH, ODOR, ETC.) DRE EVALUATION STATEMENTS UNKNOWN OTHER (Explain)

CONSTRUCTION MAINTENANCE /23 UTILITY

LIGHTS STUCK GATES INOPERATIVE GATE ARM MISSING

RESULTS OF TEST:

D 1 ____% D 2 ____%

SNOW

OTHER RR MALFUNCTN

NO TEST GIVEN

SCHOOL

OTHER IMPAIRMENT

TEST REFUSED

UNKNOWN WORK

UNKNOWN

TESTED FOR DRUGS

OTHER

RESLTS NOT AVAILABLE

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