crash form

CRASH FORM Site No. __________ 1. Case No. ___________________

CRASH FORM

2. Day of week crash occurred ____A.2.2

(1) Monday

(2) Tuesday

(3) Wednesday

(4) Thursday

(5) Friday

(6) Saturday

(7) Sunday

3. Time of day crash occurred ___ ___:___ ___ A.2.1

(24-hour clock)

4. Crash Location (GPS Coordinates):

Latitude ______° ______’ _______ _______

Degree, minutes, seconds, direction

Longitude ______° ______’ _______ _______

Degree, minutes, seconds, direction

5. Motorcycle involved in collision with ____ A.2.4

(1) Other motor vehicle

(2) Other parked motor vehicle

(3) Roadway

(4) Off road environment, fixed object

(5) Bicycle

(6) Pedestrian

(7) Animal

(8) Other. specify _________________________________

(9) Unknown

6. If this case is a MC vs. MC, provide matching case number _______________

7. Presence at crash scene ____ ____

Code up to 4 ____ ____

(00) Not on-scene ____ ____

(01) Nothing present ____ ____

(02) Crash vehicles present

(03) Police present

(04) EMS present

(05) Motorcycle Rider present

(06) Motor Vehicle Driver(s) present

(07) Motorcycle Passengers present

(08) Motor Vehicle Passengers present

(09) Non-motorists present

(98) Other present (specify):_____________________________

(99) Unknown

8. How many other vehicles were involved in the accident? ____A.2.5

(1) One

(2) Two

(3) Three

(4) Four or more

(7) Not applicable

(8) Other, specify _________________________________

(9) Unknown

9. How many pedestrians were involved in the accident? ____A.2.6

(1) One

(2) Two

(3) Three

(4) Four or more

(7) Not applicable

(8) Other, specify _________________________________

(9) Unknown

10. Number of passengers on the motorcycle ____A.2.7

(0) None

(1) One

(2) Two

(3) Three

(4) Four

(5) Five

(6) Six

(9) Unknown

11. Are there any fatal injuries involved? ____A.2.8

(1) No

(2) Yes

(9) Unknown

12. Accident configuration ___ ___ A.2.9

(01) Head-on collision of MC and OV

(02) OV into MC impact at intersection; both vehicles proceeding straight ahead, paths perpendicular

(03) MC into OV impact at intersection; both vehicles proceeding straight ahead, paths perpendicular

(04) OV turning left in front of MC, MC proceeding in either direction perpendicular to

OV path

(05) OV turning right in front of MC, MC proceeding in either direction perpendicular to

OV path

(06) MC and OV traveling in opposite directions, OV turns in front of MC, crossing MC

path, OV impacting MC

(07) MC and OV traveling in opposite directions, OV turns in front of MC, crossing MC

path, MC impacting OV

(08) MC turning left in front of OV, OV proceeding in either direction perpendicular to

MC path

(09) MC turning right in front of OV, OV proceeding in either direction perpendicular to

MC path

(10) MC overtaking OV while OV turning left

(11) MC overtaking OV while OV turning right

(12) OV impacting rear of MC

(13) MC impacting rear of OV

(14) Sideswipe, OV and MC traveling in opposite directions

(15) Sideswipe, OV and MC traveling in same directions

(16) OV making U-turn or Y-turn ahead of MV

(17) Other MC/OV impacts

(18) MC falling on roadway, no OV involvement

(19) MC running off roadway, no OV involvement

(20) MC falling on roadway in collision avoidance with OV

(21) MC running off roadway in collision avoidance with OV

(22) Other MC accidents with no OV or other involvement

(23) MC impacting pedestrian or animal

(24) MC impacting environmental object

(98) Other, specify __________________________________

(99) Unknown

13. Light Conditions ___ ___ A.3.1.2

(01) Daylight, bright

(02) Daylight, not bright

(03) Dusk, sundown

(04) Night, lighted

(05) Night, not lighted

(06) Dawn, sunup

(07) Night, continuous illumination

(08) Night, spot illumination

(98) Other, specify __________________________________

(99) Unknown

WEATHER AT TIME OF ACCIDENT

14. Ambient Temperature ___ ___ ___ A.3.1.32

(code plus (+) or minus (-); Degrees F)

(999) Unknown

15. Weather description ____A.3.1.33

(0) Clear

(1) Cloudy, partly cloudy

(2) Overcast

(3) Drizzle, light rain

(4) Moderate or heavy rain

(5) Snow

(6) Sleet, freezing rain

(7) Hail

(8) Other, specify __________________________________

(9) Unknown

16. Wind description ____A.3.1.34

(0) None, calm

(1) Light

(2) Moderate

(3) Strong

(4) Light with gusts

(5) Moderate with gusts

(6) Strong with gusts

(7) Variable

(8) Other, specify __________________________________

(9) Unknown

17. Wind direction with respect to motorcycle path ____A.3.1.35

(0) None, no wind

(1) Left crosswind

(2) Headwind

(3) Right crosswind

(4) Tailwind

(8) Other, specify __________________________________

(9) Unknown

CASE ADMINISTRATION – the following are NOT to be entered in the database

18. Team/Investigator departure time ___ ___:___ ___ A.1.12

(24 hr clock)

19. Team/Investigator scene arrival time ___ ___:___ ___ A.1.13

(24 hr clock)

Code the following in MM/DD/YYYY format.

20. Date of crash ___ ___/ ___ ___/___ ______ __ A.2.3

21. Data Scene Inspection Completed ___ ___/ ___ ___/ ___ ___ ___ ___

22. Motorcycle Inspection Completed ___ ___/ ___ ___/ ___ ___ ___ ___

23. Motor Vehicle Inspection Completed ___ ___/ ___ ___/ ___ ___ ___ ___

24. Assigned Investigator(s) a. __________________________________

b. __________________________________

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Version .05, 2/12/2007