investigating officer crash circumstances and … · 2020. 1. 28. · 108 snow 980 other 999...

Weather Conditions

000 Clear100 Blowing sand, soil, dirt101 Blowing snow102 Cloudy103 Fog, smog, smoke104 Freezing rain or freezing drizzle105 Rain106 Severe crosswinds107 Sleet or hail108 Snow980 Other999 Unknown

Rank

Badge #

First Harmful Event

Intersection Approach

Intersection Geometry

Investigating Agency

MISSISSIPPI UNIFORM CRASH REPORTCRASH INFORMATION

Agency # Case #Rev. 2019-3 Page of

VehiclesInvolved

City Latitude LongitudeCounty

Police Notified Date/Time Police Arrived Date/Time Roadway Cleared Date/Time 10-24 Investigation Completed

Number ofMotorists

Number ofNon-Motorists

Non-Fatally InjuredPersons

Fatalities Injuries

Crash Date/Time

Secondary Crash

100 Cargo/equipment loss or shift101 Fell/jumped from motor vehicle102 Fire/explosion103 Immersion, full or partial104 Jackknife105 Overturn/rollover106 Thrown or falling object198 Other non-collision harmful event

No

n-C

ollisio

n C

ollisio

n w

ith N

on

-Fixed

Ob

ject

200 Collision with animal (live)201 Collision with motor vehicle in transport202 Collision with parked motor vehicle203 Collision with pedalcycle204 Collision with pedestrian205 Collision with railway vehicle (train, engine)206 Collision with object at rest from MV in transport207 Falling/shifting cargo or anything set in motion by MV208 Work zone/maintenance equipment297 Collision with other non-motorist298 Collision with other non-fixed object

Co

llision

with

Fixed

Ob

ject

300 Collision with bridge overhead structure301 Collision with bridge pier or support302 Collision with bridge rail303 Collision with cable barrier304 Collision with concrete traffic barrier305 Collision with culvert306 Collision with curb307 Collision with ditch308 Collision with embankment309 Collision with fence310 Collision with guardrail end terminal311 Collision with guardrail face312 Collision with impact attenuator/crash cushion313 Collision with mailbox314 Collision with traffic sign support315 Collision with traffic signal support316 Collision with tree (standing)317 Collision with utility pole/light support396 Collision with other post, pole, or support397 Collision with other traffic barrier398 Collision with other fixed object (wall, building, tunnel, etc.)399 Collision with unknown fixed object

Location of FirstHarmful Event100 Gore101 In parking lane or zone102 Median103 Off roadway, location unknown104 On roadway105 On shoulder, left side106 On shoulder, right side107 Outside road/right-of-way108 Roadside109 Separator/traffic island999 Unknown

100 Angled / skewed101 Roundabout / traffic circle102 Perpendicular970 Not applicable

Roadway SurfaceCondition000 Dry100 Ice/Frost101 Mud, dirt, gravel102 Oil103 Sand104 Slush105 Snow106 Water (standing,moving)107 Wet980 Other999 Unknown

Manner of Crash

000 Not a collision between two motor vehicles100 Angle101 Front to front102 Front to rear103 Rear to rear104 Rear to side105 Sideswipe, opposite direction106 Sideswipe, same direction980 Other999 Unknown

Relation to Junction

000100101102103104105106107980

999

Light Condition

101 Daylight201 Dawn/Dusk301 Dark - lighted302 Dark - not lighted399 Dark - unknown lighting980 Other999 Unknown

Environmental Conditions

Intersection TrafficControl000 No controls100 Signalized101 Stop -all way102 Stop -partial103 Yield970 Not applicable

School Bus Relation

000 No100 Yes, school bus directly involved101 Yes, school bus indirectly involved

NoneAnimal(s)DebrisGlareNon-highway workObstructed crosswalksObstruction in roadwayPrior crashPrior non-recurring incidentRegular congestionRelated to a bus stopRoad surface condition(wet, icy, snow, slush, etc.)Ruts, holes,bumpsShoulders (none, low, soft, high)Toll booth/plaza relatedTraffic control deviceTraffic incidentVisual obstructionWeather conditionsWork zone (construction/maintenance/utility)Worn,travel-polished surfaceOtherUnknown

CRASH REPORT - CRASH SUMMARY

1 Not an intersection2 Two3 Three4 Four5 Five or more

Traffic Flow Direction

N North

TrafficwayCharacteristics100 Trafficway, on road101 Trafficway, not on road102 Non-trafficway

Property Ownership

100 Public property101 Private property

Named road Numbered road

Road Classification

100 Interstate101 US highway102 State highway103 County road104 City street

Address Number Street Name Road Number Milepost

LOCATION INFORMATION

Intersection Road Name Intersection Road NumberCrash was at an intersection

CRASH CIRCUMSTANCES AND CONDITIONS

First Name Middle Name Last Name Suffix

Printed Name Signature

CRASH TIME INFORMATION

INVESTIGATING OFFICER

INTERSECTION INFORMATION

000100101102103104105106107108109110

111112113114115116117118

119980999

Not an interchange areaAcceleration or deceleration laneCrossover relatedDriveway access or relatedEntrance/exit ramp or relatedIntersection or relatedNon-junctionRailway grade crossingShared-use path or trailOther location within an interchangearea (median, shoulder, and roadside)Unknown

200

201202

Parking lot/private driveState parkOff road

Not applicable(not a divided highway)

X

S South

W West E East

SAMPLE

Conductor ID Number

TRAIN CRASH INFORMATION

Company

Engineer

ConductorFirst Middle Last Suffix

Unknown

Unknown

DOT Crossing Number UnknownUnknown

Engineer ID Number Unknown

Unknown

Middle Last SuffixFirst

TRAIN #


Agency #Rev. 2019-3 Page ofCase #

CRASH REPORT - SUMMARY BACK

Work Zone Type Law Enforcement PresentWork Zone

WORK ZONE CRASH INFORMATION

000 No100 Yes999 Unknown

Location Relativeto Work Zone100 Before the first work zone warning sign101 Advance warning area102 Transition area103 Activity area104 Termination area999 Unknown

000 No law enforcement presence100 Officer present101 Law enforcement vehicle only present970 Not applicable999 Unknown

Worker(s) Present

000 No100 Yes970 Not applicable999 Unknown

100 Lane closure101 Lane shift or crossover102 Work on shoulder or median103 Intermittent or moving work980 Other999 Unknown

Photos Taken? Rank First Name Middle Name Last Name Suffix

PHOTOGRAPHER

REVIEWING OFFICER

First Name Middle Name Last Name SuffixRank

City

WITNESS #

Name

Address

Phone Number Age

Postal Code

Sex

WITNESS #

State City

Name

Address

Phone Number Age

Postal Code

Sex

State

First Middle Last First Middle LastSuffix Suffix

City

WITNESS #

Name

Address

Phone Number Age

Postal Code

Sex

WITNESS #

State City

Name

Address

Phone Number Age

Postal Code

Sex

State

First Middle Last First Middle LastSuffix Suffix

City

WITNESS #

Name

Address

Phone Number Age

Postal Code

Sex

WITNESS #

State City

Name

Address

Phone Number Age

Postal Code

Sex

State

First Middle Last First Middle LastSuffix SuffixSAMPLE

DESCRIPTION AND INFORMATION

Page

MISSISSIPPI UNIFORM CRASH REPORTVEHICLE INFORMATION

Agency # Case # ofMotor Vehicle #

Rev. 2019-3

CRASH REPORT - MOTOR VEHICLE DESCRIPTION AND IDENTIFICATION

Tow Status

Insurance

ColorModelModel Year Make

Tow Authority

Initial Contact PointDamage Extent Damaged Areas

Hit and Run

000 No, did not leave the scene100 Yes, driver and vehicle left scene101 Yes, only driver left scene

Vehicle Body Type

100 Passenger car101 Passenger van (less than 9 seats)102 Sport utility vehicle

300 2-wheeled motorcycle301 3-wheeled motorcycle302 Moped or motorized bicycle303 All-terrain vehicle / all-terrain cycle (ATV / ATC)304 Golf Cart305 Snowmobile306 Low Speed Vehicle307 Recreational off-highway vehicles (ROV)308 Autocycle

Passenger Vehicles

Cycle / Low Speed

Towed By

100 Top

12345

6

1110987

12

000 Non-collision

100 Top

999 Unknown

113 Undercarriage

114 Cargo Loss

DAMAGE

000 None100 Minor damage101 Functional damage102 Disabling damage990 Vehicle not at scene

State Property Damaged

TOWING

License Plate

State

Missing

Unknown

Owner Name Same as driver Unknown

Owner Address Same as driver Unknown

City State Postal CodeStreet

Uninsured at time of crash

VIN

Check if this vehiclehad no driver

200 Construction equipment (backhoe, bulldozer,etc.)201 Farm equipment (tractor, combine,harvester, etc.)

Construction / Farm Equipment

Other

400 Single unit truck401 Truck tractor498 Other truck

505 School bus506 Transit bus507 Motorcoach598 Other bus / large passenger vehicle

Trucks

Large Passenger Vehicle

980 Other

Vehicle Type

100 Motor vehicle in transport101 Parked motor vehicle102 Working vehicle / equipment

Unknown

500 Motor home501 9 or 12 passenger van502 15-passenger van503 Large limo504 Mini-bus

1235

6

1110987

12

4

Unknown

001 Vehicle not at scene

001 Vehicle not at scene

103 Pickup104 Cargo van

Number YearUnknown Unknown

Unknown

Company Unknown

NAIC # Unknown

Policy # Unknown

113 Undercarriage

100 Owner101 Law enforcement970 Not applicable980 Other

000 None

100 Bridge overhead structure

101 Bridge pier or support

102 Bridge rail

200 Cable barrier

201 Concrete traffic barrier

202 Guardrail end terminal

203 Guardrail face

204 Impact attenuator/crash cushion

298 Other traffic barrier

300 Traffic sign support

301 Traffic signal support

302 Utility pole/light support

980 Other

000 Not towed100 Towed, but not due to disabling damage101 Towed due to disabling damage

Non-expiring

SAMPLE


Agency # Case #Motor Vehicle #

Rev. 2019-3 Page of

100 Cargo/equipment loss or shift101 Fell/jumped from motor vehicle102 Fire/explosion103 Immersion, full or partial104 Jackknife105 Overturn/rollover106 Thrown or falling object198 Other non-collision harmful event

200201202203204205206207

208298

300 Collision with bridge overhead structure301 Collision with bridge pier or support302 Collision with bridge rail303 Collision with cable barrier304 Collision with concrete traffic barrier305 Collision with culvert306 Collision with curb307 Collision with ditch308 Collision with embankment309 Collision with fence310 Collision with guardrail end terminal311 Collision with guardrail face312 Collision with impact attenuator/crash cushion313 Collision with mailbox314 Collision with traffic sign support315 Collision with traffic signal support316 Collision with tree (standing)317 Collision with utility pole/light support

396

397398

399

Non-Collision Events Collision with Person / Vehicle / Non-Fixed Object

Collision with Fixed Object

Sequence of Events 1 2 3 4 Most Harmful Event

MOTOR VEHICLE EVENTS

Vehicle Usage

000 No special function100 Bus - school (public or private)101 Bus - childcare / daycare102 Bus - transit / commuter103 Bus Charter / tour104 Bus - intercity105 Bus - shuttle198 Bus -other200 Farm vehicle201 Fire truck202 Highway / maintenance203 Mail carrier204 Military205 Ambulance206 Police

Vehicle Maneuver

100 Backing101 Changing lanes102 Entering traffic lane103 Leaving traffic lane104 Making U-turn105 Movement essentially straight ahead106 Negotiating a curve107 Overtaking/passing108 Parked109 Slowing110 Stopped in traffic111 Turning left112 Turning right980 Other999 Unknown

Roadway Grade

100 Level101 Uphill102 Hillcrest103 Downhill104 Sag (bottom)999 Unknown

RoadwayAlignment

100 Straight101 Curve left102 Curve right

Barrier Type

000 None100 Cable barrier101 Concrete barrier (e.g. Jersey barrier)102 Earth embankment103 Guardrail980 Other

Posted Speed Limit

# of Through Lanes

Trafficway Division

Emergency Vehicle Usage

100 Non-emergency, non-transport101 Non-emergency transport200 Emergency operation, emergency warning equipment not in use201 Emergency operation, emergency warning equipment in use970 Not applicable999 Unknown

Travel Direction

000 Not on roadway

CRASH REPORT - MOTOR VEHICLE CIRCUMSTANCES AND EVENTS

207208209210211212213214215

980999

MOTOR VEHICLE CIRCUMSTANCES

Permitted Travel

100 One-way200 Two way

# of Auxiliary Lanes

Vehicle Defects

000 None100 Brakes101 Exhaust system102 Body doors103 Steering104 Power train105 Suspension106 Tires107 Wheels108 Lights (head,signal,tail)109 Window / Windshield110 Mirrors111 Wipers112 Truck coupling /trailer /hitch /safety chains980 Other999 Unknown

Traffic Control Device Types and Statuses

Traffic Control Device Types

000 None

100 Person

200 Bicycle crossing sign201 "Curve Ahead" sign202 "Intersection Ahead"203 Pedestrian crossing sign204 Railroad crossing205 "Reduce Speed Ahead"206 School zone sign207 Stop sign208 Yield sign298 Other warning sign

980 Other999 Unknown

Devices Present

300 Flashing railroad crossing301 Flashing school zone302 Flashing traffic control303 Lane use control signal304 Ramp meter signal305 Traffic control signal398 Other signal

400 Bicycle crossing401 Pedestrian crossing402 Railroad crossing403 School zone498 Other pavement marking

Devices Inoperativeor Missing

1 1

2 2

3 3

4 4

Vehicle Automation Level

000 No automation100 Driver assistance101 Partial automation102 Conditional automation103 High automation

103 High automation104 Full automation199 Automation level unknown999 Unknown

Automation Levels Engaged at Time of Crash

600 Southwest

HOV Lane Presence

000 Not Present100 Separated barrier, flush (greater than 4 ft wide), raised or depressed median101 Not separated, painted pavement markings, post-mounted delineators

HOV Lane Relation

000 No100 Yes

Unknown

N/A

000 No automation100 Driver assistance101 Partial automation102 Conditional automation103 High automation

103 High automation104 Full automation199 Automation level unknown999 Unknown

000 Not divided001 Not divided, with a continuous left turn lane100 Divided, flush median (greater than 4 ft wide)101 Divided, raised median (curbed)102 Divided, depressed median999 Unknown

Public utilityNon-transport emergency services vehicleSafety service patrols - incident responseOther incident responseRental truckTowing - incident responseTruck acting as crash attenuatorTaxiVehicle used for electronic ride-hailing(transportation network company)

OtherUnknown

100 North

200 Northeast

300 East

400 Southeast

500 South

700 West

800 Northwest

999 Unknown

Collision with animal (live)Collision with motor vehicle in transportCollision with parked motor vehicleCollision with pedacycleCollision with pedestrianCollision with railway vehicle(train,engine)Collision with object at rest from MV in transportCollision with falling, shifting cargo, oranything set in motion by MVCollision with work zone/maintenance equipmentCollision with other non-fixed object

Collision with other post,pole,orsupportCollision with other traffic barrierCollision with other fixed object(wall, building, tunnel, etc.)Collision with unknown fixed object

Non-Harmful Events

000 Cross centerline001 Cross median002 End departure (T-intersection, dead-end, etc.)003 Downhill runaway004 Equipment failure (blown tire, brake failure, etc.)

005 Ran off roadway left006 Ran off roadway right007 Reentering roadway008 Separation of units098 Other non-harmful event

SAMPLE

COMMERCIAL MOTOR VEHICLE INFORMATION

Page


Agency # Case # ofMotor Vehicle #

Rev. 2019-3

CRASH REPORT - COMMERCIAL MOTOR VEHICLE DESCRIPTION AND IDENTIFICATION

Year Model

Special Sizing Motor Carrier Type

License Plate

Make

VIN

Motor Carrier Address

Vehicle Configuration

GVWR/GCWR

Motor Carrier Identification

100 USDOT number101 State number970 Not applicable999 Unknown/unable to determine

State

City State Postal CodeStreet

Unknown

Numberof Axles000 No special sizing

Motor Carrier ID Number

Hazardous Materials Placard

000 Did not carry hazardous materials100 Carried hazardous materials with placard200 Carried hazardous materials without placard

Hazardous Material ID

Hazardous Material Class

Hazardous Materials Releasedfrom Vehicle Cargo Compartment000 No, hazardous materials not released100 Yes, hazardous materials released970 Not applicable

100 Light (less than 10,000 lbs.GVWR/GCWR)101 Medium (10,001 - 26,000 lbs GVWR/GCWR)102 Heavy (greater than 26,000 lbs GVWR/GCWR)970 Not applicable999 Unknown

Commodity Hauled

Number of Axles

100 Vehicles 10,000 lbs or less placarded for hazardous materials

200 Bus/large van (seats 9-15 occupants, including driver)201 Bus (seats more than 15 occupants, including driver)

999 Unknown

Cargo Body Type

109 Log110 Pole trailer111 Van / enclosed box112 Vehicle towing another vehicle

999 Unknown

105 Flatbed106 Garbage / refuse107 Grain/chips/gravel108 Intermodal container chassis

980 Other

000 No cargo body

100 Bus101 Auto transporter102 Cargo tank103 Concrete mixer104 Dump

970 Not applicable

000 Not a motor carrier100 Interstate carrier101 Intrastate carrier102 Not in commerce - government980 Not in commerce - other truck

Motor Carrier Name Unknown

TRAILER INFORMATION TRAILER #

License Plate

VIN Number of Axles


License Plate

VIN Number of Axles


Year ModelMake

Year ModelMake

State Number

State Number

State Number

123456789

970999

100 Over-height

101 Over length

102 Over-weight

103 Over-width

Unknown Unknown

Unknown UnknownUnknown

Unknown Unknown

Missing

Unknown

Unknown

Missing

Unknown Unknown

Unknown

Unknown Unknown

UnknownUnknown

Missing

Unknown Unknown

Unknown UnknownUnknown

300 Single-unit truck (2-axle and GVWR > 10,000 lbs.)301 Single-unit truck (3 or more axles)302 Truck pulling trailer(s)303 Truck tractor (bobtail)304 Truck tractor/semi-trailer305 Truck tractor/double306 Truck tractor/triple307 Truck more than 10,000 lbs., cannot classify

ExplosivesGasFlammable liquidsOther flammable substancesOxidizing substances and organic peroxidesToxic (poisonous) and infectious substancesRadioactive materialCorrosivesMiscellaneous dangerous goodsNot applicableUnknown

Unknown

999 Unknown

999 Unknown

SAMPLE

Air Bags Deployed

Motor Vehicle #

Name

DRIVER INFORMATION

AddressFirst

Street

Seating Position

DRIVER SEATING AND SAFETY INFORMATION

MISSISSIPPI UNIFORM CRASH REPORTDRIVER INFORMATION


Restraint Systems Used

100 None used - motor vehicle occupant101 Booster seat102 Child restraint system - forward facing103 Child restraint system - rear facing104 Child restraint - type unknown105 Lap belt only used106 Shoulder and lap belt used107 Shoulder belt only used108 Stretcher109 Wheelchair199 Restraint used - type unknown

Race

100

101102103980999

SexAge

Middle Last Suffix

City State Postal Code

Unknown

Unknown

Front

Row Left Middle Right

1

2

3

4

Oth

Unk

100

200

300

400

500

101

201

301

401

501

102

202

302

402

502

199

299

399

499

599

700 Unenclosed cargo area701 Riding on motor vehicle exterior (non-trailing unit)800 Trailing unit801 Sleeper section of cab (truck)898 Other enclosed cargo area970 Not applicable999 Unknown

Ejection

000 Not ejected100 Ejected, partially101 Ejected, totally970 Not applicable999 Unknown

200 No helmet201 DOT-compliant motorcycle helmet202 Non-DOT-compliant motorcycle helmet299 Unknown if DOT-compliant motorcycle helmet

Used Improperly?

Standard Vehicle Seats Other Seating Positions

Extrication

000 No100 Yes

Unk 600 601 602 699

Phone Number Unknown

Unknown

Ethnicity

100 Hispanic101 Other than Hispanic999 Unknown

Date of Birth

Endorsements on License

DRIVER LICENSE INFORMATIONLicense Status

100 Valid license000 Not licensed001 Canceled or denied002 Expired003 Revoked004 Suspended999 Unknown

Alcohol Interlock Presence

Restrictions on License

100 H - Hazardous materials

101 N - Tank vehicle

102 P - Passenger

103 S - School

104 T - Double/triple trailers

105 X - Combination of tank/HAZMAT

980 Other non-commercial license endorsements

999 Unknown

Endorsement Compliance

License Number

License State

License Class

Is Commercial DL?

Yes No

000 No100 Yes

000 None/not applicable

Commercial Driver License Status

100 Valid101 Learner's Permit

000 Canceled or denied001 Disqualified002 Expired003 Revoked004 Suspended098 Other (not valid)

000 Not deployed

100 Front

101 Side

102 Curtain

103 Other (knee, air belt, etc.)

970 Not applicable

999 Deployment unknown

Incident Responder

CRASH REPORT - DRIVER INFORMATION

Unknown

000 No endorsements required for the vehicle100 Endorsements required, complied with101 Endorsements required, not complied with199 Endorsements required, compliance unknown999 Unknown if endorsements required

000 No100 EMS101 Fire

102 Police103 Tow operator104 Transportation (i.e. maintenance workers, safety service patrol operators, etc.)


999 Unknown

970 Not applicable999 Unknown

100 Female101 Male999 Unknown

000 None100 Class A101 Class B102 Class C200 Light commercial/taxi/chauffeur (MS class D)300 Motorcycle only (class M, non-MS only)400 Regular driver license class (MS classes R, T, P, and Y)970 Not applicable


970 Not applicable980 Other999 Unknown

American Indian/Alaska NativeAsian/Pacific IslanderBlackWhiteOtherUnknown

SAMPLE

Conditions at Time of Crash

Apparently normalAsleep or fatiguedEmotional (depressed, angry, disturbed, etc.)Ill (sick), faintedPhysically impairedUnder the influence of medications/drugs/alcoholNot applicableOtherUnknown

Avoidance ManeuverDriver Actions at Time of Crash

EMS Response Run #

Injury Status

MISSISSIPPI UNIFORM CRASH REPORTDRIVER INFORMATION


Distraction SourceDistracted By

000100101

980999

Speeding Related

000 No100 Exceeded speed limit101 Racing102 Too fast for conditions999 Unknown

Type of Medical Transportation

000 Not transported100 EMS air101 EMS ground200 Law enforcement980 Other999 Unknown

EMS Response Agency

Facility Receiving Patient

100 Hands-free mobile phone101 Hand-held mobile phone102 Vehicle-integrated device198 Other electronic device200 Passenger or other non-motorist201 External to vehicle/non motorist area298 Other970 Not applicable999 Unknown

000 No contributing action

100 Disregard other road markings101 Disregard other traffic sigs102 Failed to keep in proper lane103 Failed to yield right-of-way104 Followed too closely105 Improper backing106 Improper passing107 Improper turn108 Operated motor vehicle in attentive, careless, negligent, or erratic manner109 Operated motor vehicle in reckless or aggressive manner110 Over-correcting or over-steering111 Ran off roadway112 Ran red light113 Ran stop sign114 Swerved or avoided due to wind,slippery surface,motor vehicle,object,non-motorist in roadway,etc.115 Wrong side or wrong way

980 Other contributing action999 Unknown

Motor Vehicle #

MEDICAL INFORMATION

DRIVER CONDITION AND CIRCUMSTANCES

100 (K) Fatal Injury101 (A) Suspected Serious Injury102 (B) Suspected Minor Injury103 (C) Possible Injury104 (O) No Apparent Injury

000100101102103104

970980999

CRASH REPORT - DRIVER CONDITION AND CIRCUMSTANCES

SuspectedDrugUsage

SuspectedAlcoholUsage


Alcohol Test Results

Test Status Drug Test Results

000 Results pending001 Negative results with no actual value100 Results received101 Positive results with no actual value970 Not applicable999 Unknown

BAC

Drug Test Type

000 Test not given001 Test refused100 Test given999 Unknown if tested



100 Blood101 Urine102 Both blood and urine103 Saliva198 Other

Alcohol Test Type

100 Blood101 Blood clot102 Blood plasma/serum

300 Urine301 Vitreous

Test Status


DRIVER ACTIONS

000 No avoidance maneuver

100 Accelerating101 Accelerating and steering left102 Accelerating and steering right103 Braking and steering left104 Braking and steering right105 Braking (lockup)106 Braking (no lockup)107 Braking (lockup unknown)108 Releasing brakes109 Steering left110 Steering right


Unknown

Not distractedTalking / listeningManually operating an electroniccommunication device (texting, typing,dialing, playing game, etc.)OtherUnknown

970 Not applicable980 Other

200 Breath201 Preliminary breath test (PBT)

CITATIONS

SAMPLE

MISSISSIPPI UNIFORM CRASH REPORTPASSENGER INFORMATIONTotal # of Passengers

PageAgency # Case # ofRev. 2019-3

PASSENGER INFORMATION

Ejection

000 Not ejected100 Ejected, partially101 Ejected, totally970 Not applicable999 Unknown

Extrication

000 Not extricated100 Extricated

Injury Status

100 (K) Fatal injury101 (A) Suspected serious injury102 (B) Suspected minor injury103 (C) Possible injury104 (O) No apparent injury

Race

100 American Indian or Alaska Native101 Asian/Pacific Islander102 Black103 White980 Other999 Unknown

Restraint Systems

100 None used - motor vehicle occupant101 Booster Seat102 Child restraint system - forward facing103 Child restraint system - rear facing104 Child restraint system - type unknown105 Lap belt only used106 Shoulder and lap belt used107 Shoulder belt only used108 Stretcher109 Wheelchair199 Restraint used - type unknown



Seating Position

Front

Row Left Middle Right

1

2

3

4

Other

Unk

100

200

300

400

500

101

201

301

401

501

102

202

302

402

502

199

299

399

499

599

700 Unenclosed cargo area701 Riding on motor vehicle exterior (non-trailing unit)800 Trailing unit801 Sleeper section of cab (truck)898 Other enclosed cargo area970 Not applicable999 Unknown

PASSENGER CODES

Ethnicity


Unk 600 601 602 699

200 No helmet201 DOT-compliant motorcycle helmet202 Not DOT-compliant motorcycle helmet299 Unknown if DOT-compliant motorcycle helmet

970 Not applicable980 Other999 Unknown

Incident Responder

000 No100 EMS101 Fire102 Police103 Tow operator104 Transportation


(i.e. maintenance workers, safety service patrol operators, etc.)

CRASH REPORT - PASSENGER INFORMATION

EMS Response Run #

Name

Address

PASSENGER #


Date of Birth Sex

Phone Number Ethnicity

EMS Response Agency

Injury Status Seating PositionRestraint System Ejection Extrication

Type ofMedicalTransportation


Street City State Postal Code

MOTOR VEHICLE # UNBORN CHILD OF

Air Bags Deployed

000 Not deployed

100 Front

101 Side

102 Curtain

103 Other

970 Not applicable

Incident Responder

Race

999 Unknown


Unknown

Used Improperly?

Unknown

Unknown

Age

EMS Response Run #

Name

AddressMiddle Last SuffixFirst


EMS Response Agency





Air Bags Deployed

000 Not deployed

100 Front

101 Side

102 Curtain

103 Other

970 Not applicable

Incident Responder

Race

999 Unknown

Unknown

Used Improperly?

Unknown

Unknown

Date of Birth Sex100 Female101 Male999 Unknown

Age

EMS Response Run #

Name

AddressMiddle Last SuffixFirst


EMS Response Agency





Air Bags Deployed

000 Not deployed

100 Front

101 Side

102 Curtain

103 Other

970 Not applicable

Incident Responder

Race

999 Unknown

Unknown

Used Improperly?

000 No100 Yes

Unknown

Unknown

Date of Birth Sex100 Female101 Male999 Unknown

Age

PASSENGER #MOTOR VEHICLE # UNBORN CHILD OF

PASSENGER #MOTOR VEHICLE # UNBORN CHILD OF

999 Unknown

000 No100 Yes 999 Unknown

000 No100 Yes 999 Unknown

SAMPLE

Non-Motorist #

Contributing Circumstances

Non-Motorist Type

100198200298

300

999Safety Equipment

000

100101

102103104

Location At Time of Crash

100 Intersection - marked crosswalk101 Intersection - unmarked crosswalk102 Intersection - other103 Median/crossing island104 Midblock - marked crosswalk105 Shoulder/roadside106 Travel lane - other location

Suspected Drug Usage

Conditions at the Time of the Crash

000

100101

102103

104

970980999

Origin/Destination

100 Going to or from school (K-12)101 Going to or from transit970 Not applicable999 Unknown

Suspected Alcohol Usage


Alcohol Test Results

Test Status Drug Test Results

000001100101970999

BAC

Drug Test Type



InitialContact Point100 Front (12 o'clock)101 Right (3 o'clock)102 Rear (6 o'clock)106 Left (9 o'clock)999 Unknown


100 Blood101 Urine102 Both blood and urine103 Saliva198 Other

Alcohol Test Type

100 Blood101 Blood clot102 Blood plasma/serum200 Breath201 Preliminary breath test (PBT)

300 Urine301 Vitreous970 Not applicable980 Other

Test Status


NON-MOTORIST INFORMATION

Page

MISSISSIPPI UNIFORM CRASH REPORTNON-MOTORIST INFORMATION

Agency # Case # ofRev. 2019-3

CRASH REPORT - NON-MOTORIST INFORMATION

BicyclistOther cyclistPedestrianOther pedestrian (wheelchair,person in a building, skater,personal conveyance, etc.)Occupant of a non-motor vehicletransportation deviceUnknown

Apparently normal

Asleep or fatiguedEmotional(depressed,angry,disturbed,etc.)Ill (sick), faintedPhysically impaired

Under the influence ofmedication drugs/alcohol

Not applicableOtherUnknown

Results pendingNegative results with no actual valueResults receivedPositive results with no actual valueNot applicableUnknown

Name

AddressFirst

Street

Race

100

101102103980999

SexAge

Middle Last Suffix

City State Postal Code

Unknown

Unknown Phone Number Unknown

Unknown

Ethnicity


Date of BirthIncident Responder Unknown

000 No100 EMS101 Fire

102 Police103 Tow operator104 Transportation (i.e. maintenance workers, safety service patrol operators, etc.)



American Indian/Alaska NativeAsian/Pacific IslanderBlackWhiteOtherUnknown

NON-MOTORIST CIRCUMSTANCES

200 Signed route (no pavement marking)201 Shared lane markings202 On-street bike lanes203 On-street buffered bike lanes204 Separated bike lanes205 Off-street trails/sidepaths

300 Driveway access301 Non-trafficway area302 Shared-use path or trail303 Sidewalk


000 None 100 Helmet

101 Protective pads

102 Reflective wear

103 Lighting

104 Reflectors

980 Other

999 UnknownStruck by Vehicle #

Unborn Child of Non-Motorist #

Injury Status

100 (K)101 (A)102 (B)103 (C)104 (O)

Fatal InjurySuspected Serious InjurySuspected Minor InjuryPossible InjuryNo Apparent Injury

105106107108

109110



EMS Response Run #EMS Response Agency


Unknown

NON-MOTORIST MEDICAL INFORMATION


NON-MOTORIST CONDITION

Distraction SourceDistracted By

000100101

980999

100 Hands-free mobile phone101 Hand-held mobile phone102 Vehicle-integrated device198 Other electronic device200 Passenger or other non-motorist201 External to vehicle/non motorist area298 Other970 Not applicable999 Unknown

Not distractedTalking / listeningManually operating an electroniccommunication device (texting, typing,dialing, playing game, etc.)OtherUnknown

None (no improper action)

Darted or dashedDisabled vehicle related(working on, pushing, leaving/approaching)Entering or exiting parked or standing vehicle103 Failed to obey traffic signs, signals, or officer104 Failed to yield right-of-way

Improper passingImproper turn or mergeInattentive (talking, eating, etc.)In roadway improperly(standing, lying, working, playing)Not visible (dark clothing, no lighting, etc.)Wrong-way riding or walking

Action Prior to Crash

000100101102103

104105106198999

NoneAdjacent to roadway (e.g.,shoulder,median)Crossing roadwayWaiting to cross roadwayWalking/cycling along roadway against traffic(in or adjacent to travel lane)Walking/cycling along roadway with trafficWalking/cycling on sidewalkWorking in trafficway (incident response)In roadway -otherUnknown

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CRASH REPORT - TRAIN INFORMATION

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WITNESSES

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MISSISSIPPI UNIFORM CRASH REPORTWITNESSES

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CRASH REPORT - WITNESSES

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CRASH REPORT - DIAGRAM

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MISSISSIPPI UNIFORM CRASH REPORTDIAGRAM


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MISSISSIPPI UNIFORM CRASH REPORTNARRATIVE


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CRASH REPORT - NARRATIVE

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CRASH REPORT - PHOTOS

MISSISSIPPI UNIFORM CRASH REPORTPHOTOS


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investigating officer crash circumstances and … · 2020. 1. 28. · 108 snow 980 other 999...

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