Investigation Guideline

Investigation Guideline
All Terrain Vehicles
Revised July 2004

Please note that this investigation guideline applies only to investigations requested by the Directorate for
Epidemiology. It does not apply to ATV incidents assigned by Compliance. (See note under Headquarters
Contacts section.)

Background
Injuries and deaths associated with the use of all-terrain vehicles (ATVs) have shown an increasing trend in the last
several years since the expiration of the consent decrees between CPSC and ATV manufacturers. The increase is not
fully explained by an increase in the number of ATVs in use. Children under 16 years of age accounted for about a
third of the total estimated injuries from 1985 through 2001. Likewise, children represent about a third of the deaths.
Incident investigation reports are needed in order to provide accurate annual counts and estimates of all ATV
fatalities as well as counts and estimates of fatalities involving only 4-wheel ATVs in CPSC’s Annual Report on
ATV Deaths. Investigations help CPSC’s Directorate for Epidemiology (EP) match reports of incidents originating
from different data sources. They also provide additional information on the incident scenarios that the directorate
uses to address analysis requests from the Office of the General Counsel (OGC). The directorate also periodically
publishes other detailed reports used by a variety of outside groups and epidemiologists in their own research.
The Directorate for Epidemiology is revising the ATV investigation guideline at the request of the Directorate for
Field Operations in order to bring it up-to-date with changes in the market and in data needs. This revision
represents a substantial change from the previous version.

What is an ATV?
An all-terrain vehicle is a vehicle with a motor, a seat that the rider straddles, motorcycle-type handlebars, and lowpressure tires. ATVs are designed for off-road use on a variety of surfaces and terrains. Most currently manufactured
ATVs of which the agency is aware have four or more tires, but some older models have only three tires.
Please note that vehicles that do not have both a straddled seat and motorcycle-type handlebars do not qualify as
ATVs for the purposes of our epidemiological studies. Some products that have bench seats or steering wheels are
marketed as ATVs but do not meet the technical definition of an ATV. The investigator should complete an
abbreviated report on any case in which it is determined that an ATV was not involved, unless the incident falls
under a different investigative category. The abbreviated report should include a description of the vehicle. If the
investigation reveals that no consumer product was involved, a screening report may be submitted. If there is any
question about whether the concerned vehicle is an ATV or whether a full investigation should be completed, please
contact Robin Ingle at headquarters (301-504-7333).

ATV Investigation Guideline

page 1 of 5

Headquarters Contacts
For information on investigations of fatal ATV incidents, contact:
Robin Ingle, Mathematical Statistician
Hazard Analysis Division
301-504-7333
For information on investigations of other ATV incidents requested by the Office of Compliance, contact the Office
of Compliance directly.
Please note that this investigation guideline does not apply to ATV incidents assigned by Compliance. The
Office of Compliance may have very different data needs than the Directorate for Epidemiology. Any ATV incident
investigation that uncovers a product defect should be brought to the attention of Compliance, regardless of who
requested the investigation. If an investigation requested by Compliance involves an ATV fatality, this guideline
should be used in addition to Compliance’s guidance.

Instructions on Collecting Specific Information
1. Essential Information : The Directorate for Epidemiology has specific informational needs unique to
ATV investigations. The Division of Hazard Analysis (EPHA) has worked closely with field management
to provide guidance in obtaining needed information.
ATV investigational reports need not be written with distinct pre-incident, incident and post-incident
sections as they have been in the past. However, the report should include certain essential facts in the
narrative section. These are usually available from either the police report or the full medical examiner’s
report. The narrative report should be a well-written chronological account. Both the written narrative and
the ATVD online questionnaire are essential to the report, as are the collected documents that back up the
information contained in them.
For incidents in which the source document is not a death certificate, please obtain both the police report
and the full medical examiner’s report. For incidents originating from death certificates, please obtain a
police report. The source document should also be examined for any essential information it may provide.
If this essential information is not available from written law enforcement reports, medical examiner
reports, or the source document, please make every effort to obtain the information elsewhere. Please note
restrictions in the Field Investigations Manual on contact of next -of-kin by state.

Essential information required by EPHA includes:
A. Type of vehicles involved in incident.
If the vehicle does not meet the technical definition of an ATV (described above), an abbreviated
report may be submitted describing the involved vehicle. However, if the incident falls under a
different investigation category, the full investigation should be completed using the requirements for
that category.
B. Number of wheels of each involved ATV.
If the number of wheels is not available from reports or interviews, obtain police photos if available.
C. Number of ATVs and other vehicles involved.
D. Scenario description.

ATV Investigation Guideline

page 2 of 5

This should be written as a narrative and should include any details relevant to the incident, including
what happened just before, during and after the incident. It need not be written in three separate
sections, but all relevant facts should be included here. Discrepancies amo ng any official reports
collected should be noted and resolved in the narrative section of the report.
E. Date and location of death of all deceased persons involved in incident.
The location should include city, county and state. If these are not available, even the name of a
hospital where a victim died can be helpful. Please note that in many cases location of incident and
place of death differ. The coroner/medical examiner should be considered the authority on place of
death (for instance, if the police say the victim died at the scene but the medical examiner’s report or
death certificate lists somewhere else as the place of death the information provided by the ME should
be included in the investigation as the place of death. Generally the ME’s place of death is the place
where the victim was pronounced dead.) Discrepancies among any official reports collected should be
noted and resolved in the narrative section of the report.
F.

Age and gender of all deceased persons and of driver and other riders, if any (even if driver and
other riders survived the incident).

G. Date and location of incident.
Please note that in many cases location of incident and place of death differ. Location of incident
should include city and state. If no city name is available, describe location as well as possible (e.g.
Smith State Park).
H. Victim ridership status
This refers to whether the victim was the driver of an ATV, a passenger (including where positioned),
a bystander, a driver of a different vehicle, or something else.
I.

Brand, model and engine size (in cc’s) of ATVs involved.
If any of these three are not available from reports or interviews, obtain VIN number if possible. If that
fails, obtain police photos if available. Note that if brand and model are obtained, frequently engine
size can be determined from a manufacturer’s website.

J.

Number of riders (including driver and passengers) on the ATV at the time of the incident.

K. Whether the incident happened on a public road, on a non-public road, or in some other place.
L. Cause of death for all deceased persons involved in the incident.

2. Other Relevant Information: Include this information if it is obtained as a result of obtaining the
essential information in section 1, or if relevant to the incident. The collection of this information aids
EPHA in answering requests from OGC for detailed analyses of ATV hazards, as well as requests from
other divisions within CPSC and from the public.

A.
B.
C.
D.
E.
F.

Model year of ATV
Helmet usage
Height and weight of driver of ATV (regardless of whether victim was driver)
Did vehicle overturn, land on or run over victim? In what position was the ATV found?
Alcohol and drug usage prior to the incident (confirmed or suspected)
Was incident work-related?
This includes work done on a farm, even if a child was performing the work.
G. If the ATV hit something, what was it? Was the object that was hit in motion?
H. Was the victim ejected, was s/he thrown off or did s/he fall off the ATV? Did the ATV go airborne?
Was the victim found after the incident in contact with the ATV?

ATV Investigation Guideline

page 3 of 5

I.

What happened to the survivors? Did they completely recover?

Please note that this is a guideline, not a checklist. Any relevant information discovered in the course of the
investigation should be included regardless of whether it has been anticipated or excluded here.

3. Information that is necessary only if the investigation warrants its inclusion: A wide variety of
information not anticipated above may be relevant to the incident, though EPHA does not consider it to be
absolutely essential in its analyses of ATV fatalities. A partial listing is included below for the
investigator’s consideration for inclusion in the narrative section of the report. Items included here are
judgment calls that should be made by the investigator. If you are unsure whether items listed here should
be mentioned in the investigative report, please feel free to call the headquarters contact.
A. Use of safety equipment other than helmet
B. Visibility conditions (dust being kicked up by other ATVs, etc.)
C. How did driver learn to operate the ATV?
D. What was the driver’s experience with ATVs?
E. Type of terrain (road, trail, sand, lawn, woods, desert, mountains, etc.)
F. Weather conditions
G. Scene lighting conditions
H. Description of damage to ATV
I. Description of damage to other property
J. Did criminal charges result, or are they pending?
K. Did the incident occur as a result of illegal activity (e.g. running from police)?
L. Was the ATV towing anything?
M. Had any modifications been made to the ATV?
N. What was the ATV’s speed? Was the driver racing?
O. Road characteristics – curve, grade, smooth, bumpy, etc.
P. Who owns the ATV?
Q. Had the ATV been involved in previous incidents?
R. How was the ATV obtained?
S. Was the ATV bought new or used?
T. Maintenance history of ATV
U. Weight of ATV
V. Direction of travel
W. Accessories installed on ATV
X. Seat type and dimensions
Y. Wheel base length
Z. Victim’s use of other off-road vehicles (unless relevant to current incident)
AA. Slope inclination and direction
Because some investigators may have concerns about whether some information they obtain is relevant
enough to the incident to include in the narrative report, a few examples of scenarios and of relevant and
irrelevant information is given below. Please note that if you are uncertain about whether any information
is relevant, it’s better to include it in the narrative. Feel free to call your headquarters contact for guidance
on relevance as well.
Example 1: A 16-year-old male was driving a four-wheeled ATV on a dirt trail in a state park. The trail
made a 90-degree turn, but the decedent missed the turn and drove off the trail and over a cliff. He died of
head injuries sustained when he and the ATV hit the ground. In this case, the cliff is relevant to the incident
and should be mentioned in the investigator’s narrative.
Example 2: A 16-year-old male was driving a four-wheeled ATV on a dirt trail in a state park. The trail
made a 90-degree turn to the left. A cliff paralleled the right side of the trail after the turn. The decedent

ATV Investigation Guideline

page 4 of 5

successfully made the turn on the ATV, but lost control of the ATV afterwards. He over-corrected, drove
off the trail on the left (the side opposite the cliff) and the ATV overturned on the side of the trail. The
driver was ejected and died of head injuries. Police speculated that the over-correction might have been due
to the driver’s attempt to avoid the cliff. In this case, the cliff’s relevance is unclear. Mention of the cliff
should be made in the narrative. Had the police not speculated, the CPSC investigator should rely on
his/her own judgement and knowledge of the incident in making the decision about whether to include
mention of the cliff. When in doubt, call your headquarters contact.
Example 3: A 16-year-old male was driving a four-wheeled ATV on a dirt trail in a state park. The trail
was parallel to a cliff and about 100 feet away from the top of the cliff. The driver of the ATV lost control
of the ATV while going straight, the ATV tipped sideways and the driver was ejected. He later died of head
injuries. The cliff was not involved. In this case, the cliff is irrelevant to the incident.

A Note on Documents
Most investigations of ATV fatalities can be accomplished by obtaining law enforcement reports, and in some cases,
medical examiner’s reports. In a few cases, other documentation may be needed to answer questions about essential
information. Following are general guidelines on obtaining reports or making contacts:
Law enforcement reports: Please make every effort to obtain a written report from the investigating officials.
Photos: Photos taken by CPSC investigators are unnecessary. However, if items B or I in the essential information
section are not obtained through other means, please attempt to obtain police photos.
Medical examiner/coroner’s reports: If the source document is not an official death certificate, please obtain
written reports from the medical examiner/coroner. Generally these will take the form of an autopsy report, but may
also include a transcription of a legal inquest or an ME’s investigation. Note that MECAP reports are not death
certificates, and any investigation originating from a MECAP report should include a full ME’s report.
Interviews with investigating officials or reporters: If information obtained from official reports or news reports
contains discrepancies, inconsistencies, is incomplete or illegible, attempt to interview the investigating officials or
reporters to clarify them in order to obtain essential information.
Interviews with witnesses, next of kin, etc.: If contact with witnesses or next -o f-kin is allowed, interview them
only if essential information is not determined through law enforcement or ME reports or interviews, or if the
information obtained from official reports or interviews contains discrepancies or is illegible.

Five things that should be included in routine investigations of fatal ATV incidents:
• Form 182
• Supporting documentation (law enforcement reports, etc., detailed in this guideline). Police photos should only be
obtained if items B or I in the essential information section are not obtained through other means.
• A well-written chronological account of the incident including essential information (see items A-L of section 1)
• List of attachments
• ATVD online questionnaire with at least answers to questions 1, 2, 3, 5, 6, 7, 10, 12 and 16 on the questionnaire.
(Note that other questions should be answered if information is available as a result of obtaining answers to the
essential questions.) Question 7 is automatically filled in once block 6 of form 182 is completed in IFS.

ATV Investigation Guideline

page 5 of 5