Environment

ENVIRONMENTAL FORM Site no. _________ 1. Case No. ___________

ENVIRONMENTAL FORM

2. Vehicle ___ ___ ___

(ex. MC1, MV1)

TRAFFICWAY DEFINITION AND CONDITION

3. Type of Land Development 3a. same side of street ___ ___ A.3.1.1

(11) Urban industrial 3b. other side of street ___ ___ A.3.2.1

(12) Urban commercial/business

(13) Urban housing: apartments

(14) Urban housing: single-family homes

(15) Urban school

(16) Urban park

(21) Rural farming, ranching, etc.

(22) Rural wilderness

(23) Rural school

(24) Rural park

(98) Other, specify __________________________________

(99) Unknown

4. Relation to Junction ____ A.3.1.3

(0) Non-junction

(1) At-grade intersection area

(2) Interchange area

(8) Other, specify __________________________________

(9) Unknown

5. Type of At-Grade Intersection ____ ____

(00) Not at intersection

(01) Four-leg intersection, not skewed

(02) Four-leg intersection, skewed

(03) T-intersection

(04) Y intersection

(05) Intersection as part of interchange

(06) Roundabout or traffic circle, describe ___________________________

(07) Multi-leg (five-leg or more) intersection, describe ____________________

(08) Rail/light-rail crossing

(98) Other, specify __________________________________

(99) Unknown

6. Direction of traffic flow 6a. right side ____ A.3.1.4.1/A.3.2.4.1

(1) No adjacent lane 6b. left side ____ A.3.1.4.2/A.3.2.4.2

(2) Same direction

(3) Opposite direction

(4) Both directions

(7) Not applicable

(8) Other, specify __________________________________

(9) Unknown

7. Parked vehicle presence 7a. right side ____

(0) None 7b. left side ____

(1) Parallel parked vehicles

(2) Angle parked vehicles

(3) Loading zone, parked vehicles

(8) Other, specify __________________________________

(9) Unknown

8. Shoulder and sidewalk presence 8a. right side ____

(0) None 8b. left side ____

(1) Shoulder, describe __________________________

(2) Sidewalk, describe __________________________

(8) Other, specify __________________________________

(9) Unknown

PAVEMENT MARKINGS, LONGITUDINAL

9. Pavement Markings Function and Color 9a. right side ____ ____

(00) None 9b. left side ____ ____

(01) Centerline, skip-dash, yellow

(02) Centerline, solid, yellow

(03) Centerline, solid double, yellow

(04) Lane line, skip-dash, white

(05) Lane line, solid, white

(06) Edge line, left, yellow

(07) Edge line, right, white

(08) Left-turn lane lines, combination of solid and skip-dash, yellow

(09) Turn arrow symbols, thru, left, or combination of two

(98) Other, specify __________________________________

(99) Unknown

10. Pavement Markings Material 10a. right side ____

(0) None 10b. left side ____

(1) Paint

(2) Thermoplastic

(3) Raised markers

(4) Tape

(8) Other, specify __________________________________

(9) Unknown

11. Delineator presence 11a. right side ____ ____ A.3.1.5.1/A.3.2.5.1

(00) None 11b. left side ____ ____ A.3.1.5.2/A.3.2.5.2

(04) Guardrail or barrier

(05) Fence

(06) Curb

(07) Shoulder

(08) Posts or columns

(09) Cable and posts

(10) Embankment

(98) Other, specify __________________________________

(99) Unknown

12. Roadside environment 12a. right side ____ ____ A.3.1.6.1/A.3.2.6.1

12b.left side ____ ____ A.3.1.6.2/A.3.2.6.2

(01) Level ground, no remarkable features

(02) Grass, ground cover

(03) Shrubbery

(04) Dirt, soft soil, sand

(05) Gravel preparation

(06) Sidewalk

(07) Paved or topped surface

(08) Trees, posts

(98) Other, specify __________________________________

(99) Unknown

13. Roadside fixed objects 13a. right side ____ ____ A.3.1.7.1/A.3.2.7.1

(00) None 13b.left side ____ ____ A.3.1.7.2A.3.2.7.2

(01) Wall, building, tunnel, etc.

(02) Ditch or low lying area, describe

(04) Trees

(09) Impact attenuator/crash cushion

(10) Bridge pier or support

(11) Bridge rail

(12) Culvert, describe __________________________

(13) Curb, describe __________________________

(14) Embankment foreslope, describe __________________________ slope = 1V:xH

(15) Embankment transverse-slope describe __________________________ slope = 1V:xH

(16) Cut slope, backslope

(17) Guardrail

(18) Concrete traffic barrier

(19) Other traffic barrier

(20) Utility pole, light support

(21) Traffic sign support

(22) Other post, pole or support

(23) Fence

(24) Mailbox

(97) Not applicable

(98) Other, specify __________________________________

(99) Unknown

ROADWAY VEHICLE WAS TRAVELING

14. Trafficway Description ___

(1) Two-way, undivided

(2) Two-way, with a continuous left-turn lane

(3) Two-way, divided, no median barrier

(4) Two-way, divided, with median barrier

(5) One-way

(8) Other, specify __________________________________

(9) Unknown

15.Roadway Function ___ ___ A.3.1.8/A.3.2.8

(00) None

(01) Interstate/freeway mainline

(02) Freeway entrance ramp

(03) Freeway exit ramp

(04) Freeway transition (freeway to freeway)

(05) Freeway frontage road

(06) Principal arterial, non-freeway

(07) Minor arterial

(08) Collector

(09) Local road/street

(10) Construction detour

(11) Parking area, off-street

(12) Alley

(13) Driveway

(14) Round about or traffic circle (*describe, 80 characters)

(15) Overpass mainline

(16) Overpass entrance ramp

(17) Overpass exit ramp

(18) Underpass mainline

(19) Underpass entrance ramp

(20) Underpass exit ramp

(21) Dedicated bicycle/moped path separated from ordinary vehicular traffic roadway

(22) Dedicated bicycle/moped path not separated from ordinary vehicular roadway

(23) Unseparated HOV lane

(24) Separated HOV lane

(98) Other, specify __________________________________

(99) Unknown

16. Posted speed limit in MPH ____ ____ A.3.1.9/A.3.2.9

(01-96) Actual speed limit

(97) Not applicable, no posted limit

(98) Other, specify __________________________________

(99) Unknown

17. Number of through lanes ___ ___ A.3.1.10/A.3.2.10

(01-08) Number of lanes

(97) Not applicable

(99) Unknown

18. Lane vehicle was traveling ____ ____ A.3.1.11A.3.2.11

(01-09) Actual lane number

(10) Right turn only

(11) Left turn only

(12) Vehicle traveling opposite intended traffic, any lane

(97) Not applicable, vehicle not in a lane

(98) Other, specify __________________________________

(99) Unknown

19. Lane width In feet/inches ___ ___ / ___ ___ A.3.1.12/A.3.2.12

(99/97) Not applicable, vehicle not in a lane

(99/99) Unknown

20. Travel-way width In feet/inches ___ ___ / ___ ___ A.3.1.13/A.3.2.13

(99/97) Not applicable

(99/99) Unknown

ROADWAY SURFACE

21. Type of surface ___ ___ A.3.1.14/A.3.2.14

(01) Concrete

(02) Asphalt

(03) Brick

(04) Stone

(05) Gravel

(06) Dirt

(07) Metallic

(98) Other, specify __________________________________

(99) Unknown

22. Surface condition 22a. ___ ___ A.3.1.16.1/A.3.2.16.1

Code up to four 22b.___ ___ A.3.1.16.2/A.3.2.16.2

(00) None 22c. ___ ___ A.3.1.16.3/A.3.2.16.3

(01) Dry 22d. ___ ___ A.3.1.16.4/A.3.2.16.4

(02) Wet

(03) Snow

(04) Slush

(05) Ice/frost

(06) Water (standing, moving)

(07) Mud, dirt

(08) Sand

(09) Gravel

(10) Oil

(11) Debris (tire tread, construction materials, tree limbs, etc.)

(12) Loads dropped from another vehicle

(13) Tire tread debris

(98) Other, specify __________________________________

(99) Unknown

23. Surface defects and special features 23a. ___ ___ A.3.1.1.15/A.3.2.15

Code up to three 23b. ___ ___

(00) None 23c. ___ ___

(02) Surface cracking (longitudinal, transverse)

(03) Spalling (breaking up, splintering)

(04) Potholes

(05) Ruts

(06) Bump

(07) Ripples, ridges

(08) Pavement edge drop

(09) Overbanding and tar snakes, describe _____________________

(10) Bitumen repair, describe__________________________

(11) Tram//train rails

(13) Rumble strips

(14) Grooved pavement

(15) Steel plates

(16) Speed bumps/humps

(17) Bridge grating

(18) Expansion joints

(98) Other, specify __________________________________

(99) Unknown

24. Vertical alignment ____ A.3.1.17/A.3.2.17

(1) Level

(2) Upgrade

(3) Crest vertical curve

(4) Downgrade

(5) Sag vertical curve

(8) Other, specify __________________________________

(9) Unknown

25. Horizontal alignment ___ ___ A.3.1.18/A.3.2.18

(01) Straight

(02) Curve right

(03) Curve left

(04) Corner right

(05) Corner left

(06) Reverse curve right: turn to right, then left, resuming approximate original direction

(07) Reverse curve left: turn to left, then right, resuming approximate original direction

(98) Other, specify __________________________________

(99) Unknown

26. If Horizontal Alignment is any but straight, record the following:

26a. Radius ____ in feet

26b. Chord ____ in feet

26c. Middle Ordinate ____ in feet

27. Auxiliary turn only, no separate signal ___ A.3.1.19/A.3.2.19

(0) None

(1) Left turn lane, no separate signal

(2) Left turn lane, separate signal, lag time = _____ seconds

(3) Right turn lane, no separate signal

(4) Right traffic turn lane, separate signal, lag time = _____ seconds

(8) Other, specify __________________________________

(9) Unknown

TRAFFIC CONTROLS ON PATH OF TRAVEL

28. Type of Traffic Control ___ ___ A.3.1.20/A.3.2.20

(01) No traffic control

(02) Yield sign

(03) Stop sign

(04) Three-way, four-way, all-way stop

(05) Traffic control signal

(06) Traffic officer

(07) Construction personnel

(08) Gate, toll gate

(09) Pedestrian crossing

(10) Traffic calming/speed bumps

(11) Traffic advisory signage, describe ________________________________

(12) Traffic warning signage, describe ________________________________

(13) Traffic signal, actuated, two-phase

(14) Traffic signal, actuated, multi-phase

(15) Traffic signal, pre-timed, two-phase

(16) Traffic signal, pre-timed, multi-phase

(17) Traffic control signal, mid-block pedestrian crossing

(18) Flasher red

(19) Flasher yellow

(98) Other, specify __________________________________

(99) Unknown

29. Was Traffic Control Functioning Properly? ___ ___ A.3.1.21/A.3.2.21

(1) No, non-operational

(2) Yes

(3) Operational, but malfunctioning (ex: signal turn timing is incorrect)

(7) Not applicable, no traffic control

(8) Other, specify __________________________________

(9) Unknown

30. Traffic Control Visible to Vehicle Operator? ___ ___ A.3.1.22/A.3.2.22

(1) No

(2) Yes

(7) Not applicable, no traffic control

(8) Other, specify __________________________________

(9) Unknown

31. Traffic Control Violated by Vehicle Operator ___ ___ A.3.1.23/A.3.2.23

(1) No

(2) Yes

(7) Not applicable, no traffic control

(8) Other, specify __________________________________

(9) Unknown

32. Traffic density at time of accident ___ ___ A.3.1.24/A.3.2.24

(1) No other traffic

(2) Light traffic

(3) Moderate traffic

(4) Heavy traffic, traffic moving

(5) Heavy traffic, congested roadway

(8) Other, specify __________________________________

(9) Unknown

33. Visibility Limitation Due To ___ ___ A.3.1.25/A.3.2.25

(01) Not significantly limited

(02) Dust

(03) Smoke

(04) Smog

(05) Fog

(06) Precipitation

(07) Glare

(08) Windscreen, visor condition, describe_______________________

(09) Misaligned/obscured roadside curved mirror

(98) Other, specify __________________________________

(99) Unknown

34. Animal involvement ___ ___ A.3.1.26

(00) None

(01) Small dog, less than 20 pounds

(02) Big dog

(03) Cat

(04) Bird

(05) Cow

(06) Horse

(07) Deer

(08) Sheep

(09) Squirrel

(10) Elk

(98) Other, specify __________________________________

(99) Unknown

25. Was the animal struck? ___ ___ A.3.1.27

(1) No, animal not struck

(2) Yes, animal involved in precipitating event

(3) Yes, animal struck by motorcycle, or involved with motorcyclist

(7) Not applicable, no animal involved

(9) Unknown

36. Pedestrian involvement ___ ___ A.3.1.28

(0) None

(1) Yes, pedestrian involved in precipitating event

(2) Yes, pedestrian involved in collision with motorcycle or motorcyclist

(9) Unknown

37. Location of pedestrian at precipitating event 37a. Ped 1___ ___ A.3.1.29.

(01) In crosswalk 37b. Ped 2___ ___ A.3.1.29.2

(02) Jaywalking 37c. Ped 3___ ___ A.3.1.29.3

(03) Darting from roadside

(04) Passenger entering or leaving automobile

(05) Passenger entering or leaving public transportation

(06) Darting from roadside near school

(07) Entering or leaving transportation near school

(97) Not applicable, no pedestrian involved

(98) Other, specify __________________________________

(99) Unknown

38. Stationary view obstructions along the operator's line of sight

at time of precipitating event. 38a. ___ ___ A.3.1.30/A.3.2.30

(01) None 38b. ___ ___

(02) Buildings 38c. ___ ___

(03) Signs

(04) Vegetation, trees, bushes, walls, vegetation covered fences

(05) Crest vertical curve

(06) Blind horizontal curve

(07) Stationary or parked vehicles

(08) Barricades

(98) Other, specify __________________________________

(99) Unknown

39. Mobile view obstructions along the operator's line-of-sight ___ ___ A.3.1.31/A.3.2.31

at time of precipitating event.

(00) None

(02) Vehicles: automobiles

(03) Vehicles: light trucks and vans

(04) Trucks and busses

(05) Vehicles: special purpose equipment, construction, cranes

(06) Farm and/or agricultural equipment

(07) People, pedestrians

(08) Animals

(98) Other, specify __________________________________

(99) Unknown

WORK ZONE-RELATED

40. Was This Crash Work Zone-Related? ____

(1) No

(2) Yes

(9) Unknown

41. Location of Crash within Work Zone ____

(1) Not in work zone

(2) Before the first work zone warning sign

(3) Advance warning area

(4) Transition area

(5) Activity area

(6) Terminal area

(8) Other, specify __________________________________

(9) Unknown

42. Type of work zone ____

(1) Not in work zone

(2) Lane closure

(3) Lane shift/crossover

(4) Work on shoulder or median

(5) Intermittent or moving work

(8) Other, specify __________________________________

(9) Unknown

FIRST HARMFUL EVENT

43. Location Of First Harmful Event ____ ____

(01) On roadway

(02) Shoulder

(03) Median

(04) Roadside non-median

(05) Gore area

(06) Separator (between arterial and frontage road)

(07) In parking lane or zone

(08) Off roadway, location unknown

(09) Outside trafficway

(98) Other, specify __________________________________

(99) Unknown

44. If First Harmful Event is a Non-collision ___ ___

(01) Overturn

(02) Fire/explosion

(03) Immersion

(04) Jacknife

(05) Cargo/equipment loss or shift

(06) Fell/jumped from motor vehicle

(07) Thrown or falling object

(97) Not applicable, event is a collision

(98) Other, specify __________________________________

(99) Unknown

45. If First Harmful Event is a Collision with Motor Vehicle, Pedestrian,

Animal, or Fixed Object ____ ____

(01) Motor vehicle in transport

(02) Parked motor vehicle

(03) Work-zone equipment

(04) Railway/light-rail vehicle

(05) Pedestrian

(06) Pedacycle

(07) Motorcycle

(08) Animal

(97) Not applicable

(98) Other, specify __________________________________

(99) Unknown

46. If First Harmful Event is a Collision with a Fixed Object ____ ____

(01) Impact attenuator/crash cushion

(02) Bridge overhead structure

(03) Bridge pier or support

(04) Bridge rail

(05) Culvert

(06) Curb

(07) Ditch or low lying area)

(08) Embankment, foreslope

(09) Embankment transverse- slope

(10) Cut slope, backslope

(11) Guardrail non-terminal

(12) Guardrail terminal

(13) Concrete traffic barrier

(14) Other traffic barrier

(15) Trees

(16) Utility pole, light support

(17) Traffic sign support

(18) Traffic signal support

(19) Other post, pole or support

(20) Fence

(21) Mailbox

(22) Wall, building, tunnel, etc.

(97) Not applicable

(98) Other, specify __________________________________

(99) Unknown

CONTRIBUTING ENVIRONMENTAL FACTORS SUMMARY

47. Roadway Design Defect ____A.6.1.1.1

(1) Roadway design defect present but not a contributing factor

(2) Roadway design defect was the precipitating event

(3) Roadway design defect was the primary contributing factor

(4) Roadway design defect was a contributing factor

(7) Not applicable, no roadway design defect present

(9) Unknown

48. Roadway Maintenance Defect ____ A.6.1.1.2

(1) Roadway maintenance defect present, but not a contributing factor

(2) Roadway maintenance defect was the precipitating event

(3) Roadway maintenance defect was the primary contributing factor

(4) Roadway maintenance defect was a contributing factor

(7) Not applicable, no roadway maintenance defect

(9) Unknown

49. Traffic Controls Defect or Malfunction ____ A.6.1.1.3

(1) Traffic controls defect or malfunction present, but not a contributing factor

(2) Traffic controls defect or malfunction was the precipitating event

(3) Traffic controls defect or malfunction was the primary contributing factor

(4) Traffic controls defect or malfunction was a contributing factor

(7) Not applicable, no traffic controls, or traffic controls operating properly

(9) Unknown

50. Traffic hazard, including construction and maintenance operations ____A.6.1.1.4

(1) Temporary traffic obstruction present but not a contributing factor

(2) Temporary traffic obstruction was the precipitating event

(3) Temporary traffic obstruction was the primary contributing factor

(4) Temporary traffic obstruction was a contributing factor

(7) Not applicable, no temporary traffic obstruction

(9) Unknown

51. Weather Related Problem ____A.6.1.1.5

(1) Weather made no contribution to accident

(2) Weather related problem was the precipitating event

(3) Weather related problem was the primary contributing factor

(4) Weather related problem was a contributing factor

(7) Not applicable

(9) Unknown

52. Effect of the Visual Background of Motor Vehicle Along

Motorcycle Rider's Line-of-Sight at Time of Precipitating Event ____A.6.1.1.6

(1) Visual background of motor vehicle made no contribution to conspicuity of the

vehicle

(2) Visual background had a positive effect on vehicle conspicuity,

vehicle was more noticeable

(3) Visual background had a negative effect on vehicle conspicuity,

vehicle was less noticeable

(7) Not applicable, view obstructed by foreground

(9) Unknown

53. Visual Background of Motorcycle along Motor Vehicle Driver's

Line-of-Sight at Time of Precipitating Event ____ A.6.1.2.6

(1) Visual background of motorcycle made no contribution to conspicuity of motorcycle

(2) Visual background of motorcycle had positive effect on vehicle conspicuity,

made motorcycle more noticeable

(3) Visual background of motorcycle had negative effect on vehicle conspicuity,

made motorcycle less noticeable

(7) Not applicable or not applicable view obstructed by foreground

(9) Unknown

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Version .05, 2/12/2007