HS Form 433D Interview Form (A)

INTERVIEW FORM (A)

OMB No. 2127-0021

Expiration Date: xx/xx/xxxx

NATIONAL AUTOMOTIVE SAMPLING SYSTEM

CRASHWORTHINESS DATA SYSTEM

1. Primary Sampling Unit Number ___ ___ 2. Case Number – Stratum ___ ___ ___ ___ 3. Vehicle Number ___ ___	Interviewee(s) Role: ________________________________ _________________________________________________
Review all available information and interview questions prior to conducting interview(s) to ensure the acquisition of all pertinent data. If the driver was not the person interviewed, was an appointment made with the driver for a follow-up interview? Yes No
DRIVER OR OCCUPANT DESCRIPTION AND DIAGRAM OF CRASH EVENTS
_____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________	Use this space to diagram the interviewee’s crash trajectory in relationship to identifiable objects in the environment. Indicate which direction is north on the compass.
QUESTIONS TO ASK INTERVIEWEE BASED ON OTHER DATA SOURCES (VEHICLE INSPECTION, MEDICAL RECORDS, ETC.)
________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

HS Form 433D (1/2005) Information collected in this report is used to complete HS Forms 433A and 433B. A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number.  The OMB Control Number for this information collection is 2127-0021.  Public reporting for this collection of information is estimated to be approximately 30 minutes per response, including the time for reviewing instructions, completing and reviewing the collection of information.  All responses to this collection of information are mandatory.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, SE, Washington, DC 20590.

A. CRASH DATA INFORMATION
IF POSSIBLE, OBTAIN THIS INFORMATION FROM THE DRIVER
A1. Travel direction (circle appropriate direction on the compass)	If direction not known, what destination were they coming from or going to? ________________________________________ ________________________________________ N NW NE W E SW SE S
A2. Road condition (Mark only one which best applies)	Dry Wet Snow Slush Ice/Frost Water (Standing, Moving) Sand Dirt, Mud or Gravel Oil Unknown Other (describe)
A3. Weather conditions (Mark all that apply)	Fog, Smog, Smoke Rain Sleet/Hail Snow Blowing Snow Crosswinds Blowing Sand, Soil, Dirt Clear Cloudy Unknown Other (describe)
A4. Presence of sign or signal (Mark all that apply)	None (SKIP TO A6) Unknown (SKIP TO A6) Traffic control signal (includes flashing beacons, lane control signals, and green/ amber/ red signal Stop sign Yield sign School zone sign Other (describe)
A5. If sign or signal present, was it functioning properly?	Yes No (describe problem) Unknown
A6. Pre-crash travel lane (Lane 1 is the right curb lane)	1 2 3 4 Unknown Other
A7. Speed before impact?	________________ mph Stopped Unknown
A8. Before impact, intending to… (Mark all that apply)	Go straight Stop Turn left Turn right Slow down Accelerate Back up Negotiating a curve Change lanes to right Change lanes to left Unknown Other (describe)
A9. Was there loss of control? If so, due to what?	No Yes, due to mechanical problem (describe) Yes, due to weather (describe) Unknown
A10. Avoidance actions (Mark all that apply)	None Braking with lock-up Braking without lock-up Releasing brakes Accelerating Steering left Steering right Unknown Other (describe)
A11. Location of vehicle at impact	Original travel lane Different travel lane (describe) In intersection Off roadway to right Off roadway to left Unknown Other (describe)
Use this space for any additional notes about the pre-crash and impact.

B. ROLLOVER INFORMATION
B1. Did this vehicle roll over during the crash?	No (SKIP TO SECTION C BELOW) Unknown (SKIP TO SECTION C BELOW) Yes (CONTINUE)
B2. Rollover began where?	On roadway On shoulder On roadside or median Unknown
B3. Cause of rollover	Other vehicle (describe which one) Contact with object (describe) Other cause (describe) Unknown
B4. Direction of vehicle roll	Toward the right (passenger side) Toward the left (driver side) End-over-end Unknown
B5. Number of turns	______ Number of QUARTER TURNS Unknown OR ______ Number of COMPLETE TURNS
B6. Plane in contact with ground at final rest	Left side Right side Top Wheels Unknown
C. FIRE INFORMATION
C1. Did this vehicle experience a fire?	No (SKIP TO SECTION D BELOW) Unknown (SKIP TO SECTION D BELOW) Yes (CONTINUE)
C2. Fire or smoke first seen	Under the hood In the trunk/cargo area Behind the instrument panel Under the vehicle In the passenger compartment From other involved vehicle Unknown
Describe any additional rollover or fire information here:
D. DRIVER ACTIONS
D1. Prior to the crash, was the driver doing any of the following? (Mark all that apply)	Dealing with a child/passenger inside the car Looking for something inside the car Distracted by another occupant Adjusting an internal control, such as radio, climate, opening glove compartment Using a handheld device such as a cell phone or electronic organizer Eating or drinking Smoking Sleepy or fell asleep Looking for something outside of the car (street sign, building, etc.) Having personal thoughts/daydreaming/thinking Distracted by pedestrian / animal / object outside the car Other (describe) Unknown
Describe any additional driver actions just before crash:
E. ADDITIONAL VEHICLE INFORMATION
E1. Year, make, model	Year: ___ ___ ___ ___ Make: _________________________________ Model: ________________________________
E2. Vehicle mileage	__________________ miles Unknown
E3. Was there any pre-existing damage to the vehicle, or damage caused by rescue personnel?	No Unknown Yes (describe)
E4. Did any door(s) or hatch open during the crash? (Mark all that apply)	No Unknown Yes ……… Left front Right front Left rear Right rear Hatch Other (describe)
E5. Did any windows break during the crash? (Mark all that apply)	No Unknown Yes ……… Windshield Left front Right front Left rear Right rear Left rear 2 Right rear 2 BL LBL RBL Roof Other Unknown
E6. Window pre-crash status (Write in appropriate letter for all windows) F=Fixed, O=Open, P=Partially open, C=Closed, U=Unknown	__ Left front __ Right front __ Left rear __ Right rear __ Left rear 2 __ Right rear 2 __ BL __ LBL __ RBL __ Roof __ Other
E7. Cargo in the vehicle (Describe any objects in the vehicle or trunk weighing over 2 pounds)	No Unknown Yes (describe) Approximate weight of cargo: _____ pounds
E8. Location of vehicle	If vehicle has not yet been inspected, mark box below and record current location and contact person on the cover sheet. Do not record it here. Vehicle inspected Vehicle location recorded on cover sheet Insurance information recorded on cover sheet
Ask questions E9 – E11 for 2010 and newer vehicles only
E9. Is the vehicle equipped with any of the following features? (Mark all that apply)	LDW with Lane Keeping Blind Spot Detection LDW without Lane Keeping Daytime Running Light FCW with Auto Braking Assisted Braking FCW without Auto Braking Automatic Crash Notification
E10. Were any of the above features disabled at the time of the crash?	No Unknown Yes (describe)
E11. Did occupants see, hear, or feel anything to indicate activation of the above features?	No Unknown Yes (describe)

F. OCCUPANT DATA QUESTIONS

F1. Including the driver, how many people were in the vehicle at the time of the crash? ______

Please respond to each question for the driver and up to three additional occupants

DRIVER

OCCUPANT 2

OCCUPANT 3

OCCUPANT 4

F2. Seating position (Circle appropriate position of each occupant)

If “Other” location, specify ______________

Front

1	2	3
4	5	6
7	8	9
Other

Front

1	2	3
4	5	6
7	8	9
Other

Front

1	2	3
4	5	6
7	8	9
Other

Front

1	2	3
4	5	6
7	8	9
Other

F3. Sex

1. Male

2. Female, not pregnant

3. Female, Pregnant, # of months

4. Female, unknown if pregnant

1

2

3 __________

4

1

2

3 __________

4

1

2

3 __________

4

1

2

3 __________

4

If pregnant, indicate any crash related fetal complications on the mannequin page

F4. Height, Weight, Age

1. Height (Feet and inches)

2. Weight (Pounds)

3. Age (Years)

1. ___________

2. ___________

3. ___________

1. ___________

2. ___________

3. ___________

1. ___________

2. ___________

3. ___________

1. ___________

2. ___________

3. ___________

F5. Race

1. White

2. Black or African American

3. Asian

4. Native Hawaiian or Other Pacific Islander

5. American Indian or Alaska Native

6. Other (specify)

7. Unknown

1

2

3

4

5

6 __________

7

1

2

3

4

5

6 __________

7

1

2

3

4

5

6 __________

7

1

2

3

4

5

6 __________

7

F6. Ethnicity

1. Not of Hispanic origin

2. Of Hispanic origin

3. Unknown if of Hispanic origin

1

2

3

1

2

3

1

2

3

1

2

3

F7. Feet/hands/arms just prior to impact

Indicate all letters that apply and further describe as needed

FEET/LEGS

A. Both feet on floor or foot controls

B. One or both feet on dash

C. One or both feet on seat

D. Legs crossed

E. Other (describe)

F. Unknown

HANDS/ARMS

G. Both hands on steering wheel (specify o’clock positions)

H. One on wheel, other adjusting control (describe)

I. Hand(s) doing other activity (describe)

J. Bracing with one/both hands (describe)

K. Hands on lap
L. One or both arms out window
M. Other (describe)

N. Unknown

F8. Occupant wearing glasses, contacts, or have any objects in mouth/hand? (Mark if yes and describe)

Yes (Describe)

No Unk

Yes (Describe)

No Unk

Yes (Describe)

No Unk

Yes (Describe)

No Unk

G. RESTRAINT INFORMATION
	DRIVER	OCCUPANT 2	OCCUPANT 3	OCCUPANT 4
G1. Was this occupant in a child safety seat? (If yes, complete separate Child Safety Seat Form)		Yes No	Yes No	Yes No
G2. Type of seat belt available Lap belt Shoulder belt Lap and shoulder belt Not available (describe reason) Unknown	1 2 3 4 __________ 5	1 2 3 4 __________ 5	1 2 3 4 __________ 5	1 2 3 4 __________ 5
G3. Occupant wearing any seatbelt? 1. Yes 2. No 3. Unknown	1 2 3	1 2 3	1 2 3	1 2 3
G4. If seat belt worn, what was the type? Lap belt Shoulder belt Lap and shoulder belt Unknown	(Skip if seat belt not worn) 1 2 3 4	(Skip if seat belt not worn) 1 2 3 4	(Skip if seat belt not worn) 1 2 3 4	(Skip if seat belt not worn) 1 2 3 4
G5. If lap belt used, how was it positioned? Low across hips Across abdomen Used to install Child Safety Seat Other position (describe) Unknown position	(Skip if lap belt not worn) 1 2 3 4 __________ 5	(Skip if lap belt not worn) 1 2 3 4 __________ 5	(Skip if lap belt not worn) 1 2 3 4 __________ 5	(Skip if lap belt not worn) 1 2 3 4 __________ 5
G6. If lap belt used, was it snug or was there extra slack room? 1. Snug 2. Extra slack room 3. Unknown	(Skip if lap belt not worn) 1 2 3	(Skip if lap belt not worn) 1 2 3	(Skip if lap belt not worn) 1 2 3	(Skip if lap belt not worn) 1 2 3
G7. If shoulder belt used, how was it positioned? Across collarbone & over shoulder Resting on neck On edge of shoulder Under arm Behind back or seat Used to install Child Safety Seat Other position (describe) Unknown position	(Skip if shoulder belt not worn) 1 2 3 4 5 6 7 __________ 8	(Skip if shoulder belt not worn) 1 2 3 4 5 6 7 __________ 8	(Skip if shoulder belt not worn) 1 2 3 4 5 6 7 __________ 8	(Skip if shoulder belt not worn) 1 2 3 4 5 6 7 __________ 8
G8. If shoulder belt used, was it snug or was there extra slack room? 1. Snug 2. Extra slack room 3. Unknown	(Skip if shoulder belt not worn) 1 2 3	(Skip if shoulder belt not worn) 1 2 3	(Skip if shoulder belt not worn) 1 2 3	(Skip if shoulder belt not worn) 1 2 3
Describe any breaks, tears, or failures to any of the seat belts:

G. RESTRAINT INFORMATION (continued)
	DRIVER	OCCUPANT 2	OCCUPANT 3	OCCUPANT 4
G9. Was there an upper anchorage adjustment for seat belt? (If yes, indicate position) No Yes, Full up Yes, Mid position Yes, Full down 5. Unknown	1 2 3 4 5	1 2 3 4 5	1 2 3 4 5	1 2 3 4 5
G10. Was a seat belt positioning device present? (Such as a shoulder belt adjuster) 1. No 2. Yes (describe type of device) 3. Unknown	1 2 __________ 3	1 2 __________ 3	1 2 __________ 3	1 2 __________ 3
G11. If “yes” to above, was the belt positioning device in use during crash? 1. No 2. Yes 3. Unknown	1 2 3	1 2 3	1 2 3	1 2 3
G12. Seating posture Upright - back against seat back Leaning forward Leaning to the left Leaning to the right Lying on or across seat Other (describe) Unknown	1 2 3 4 5 6 __________ 7	1 2 3 4 5 6__________ 7	1 2 3 4 5 6__________ 7	1 2 3 4 5 6__________ 7
G13. Adjustable seat track position prior to impact No adjustable seat track Seat all the way forward Between forward and middle At middle position Between middle and rear position Seat all the way rearward 7. Unknown	1 2 3 4 5 6 7	1 2 3 4 5 6 7	1 2 3 4 5 6 7	1 2 3 4 5 6 7
G14. Adjustable seat back position pre-impact and post- impact 1. No adjustable seat back Completely upright Slightly reclined Completely reclined Slightly forward or upright Completely forward Unknown	PRE POST 1 1 2 2 3 3 4 4 5 5 6 6 7 7	PRE POST 1 1 2 2 3 3 4 4 5 5 6 6 7 7	PRE POST 1 1 2 2 3 3 4 4 5 5 6 6 7 7	PRE POST 1 1 2 2 3 3 4 4 5 5 6 6 7 7
G15. Adjustable pedal presence/position No adjustable pedals Full forward (toward toepan) Mid position Full rearward (toward driver) Position unknown Unknown if present	1 2 3 4 5 6

H. EJECTION, ENTRAPMENT, MOBILITY INFORMATION
	DRIVER	OCCUPANT 2	OCCUPANT 3	OCCUPANT 4
H1. Any part of body thrown outside the vehicle during the crash? No Unknown 3. Yes (describe parts of body ejected and what area of vehicle was involved)	1 2 3 (describe)	1 2 3 (describe)	1 2 3 (describe)	1 2 3 (describe)
H2. Was occupant physically pinned in the vehicle? No Unknown 3. Yes (describe entrapment)	1 2 3 (describe)	1 2 3 (describe)	1 2 3 (describe)	1 2 3 (describe)
H3. Was occupant trapped (but not pinned) in the vehicle? No Unknown 3. Yes (describe entrapment)	1 2 3 (describe)	1 2 3 (describe)	1 2 3 (describe)	1 2 3 (describe)
H4. How did occupant exit the vehicle? Fatal before removed Removed while unconscious or not oriented to time or place Removed due to perceived serious injuries Exited with some assistance Exited under own power Fully ejected Removed for other reasons (specify) Unknown	1 2 3 4 5 6 7 8	1 2 3 4 5 6 7 8	1 2 3 4 5 6 7 8	1 2 3 4 5 6 7 8
Further describe any ejection, entrapment or mobility information here.

I. AIR BAG INFORMATION
I1. Is this vehicle equipped with an air bag? (Mark yes if it had ever been equipped with an air bag) Yes (CONTINUE) No (SKIP TO SECTION J) Unknown (SKIP TO SECTION J)
I2. Air bag information (even if no passenger in that seat)	Was this air bag present?	Did it deploy in the crash?	Was there prior service on it?	Was it the original air bag, a replacement air bag, or unknown?
A. Driver air bags 1. Steering wheel hub 2. Bottom inst. panel 3. Seat back 4. Door 5. Roof side rail 6. Other ____________	Present? 1 2 3 4 5 6	Deployed? 1 2 3 UNK 4 5 6	Prior service? 1 2 3 UNK 4 5 6	Original Replacement 1 1 2 2 3 3 UNK 4 4 5 5 6 6
B. Front right air bags 1. Top instrument panel 2. Mid instrument panel 3. Bottom inst. panel 4. Seat back 5. Door 6. Roof side rail 7. Other ____________	Present? 1 2 3 4 5 6 7	Deployed? 1 2 3 UNK 4 5 6 7	Prior service? 1 2 3 UNK 4 5 6 7	Original Replacement 1 1 2 2 3 3 UNK 4 4 5 5 6 6 7 7
C. Second row left 1. Seat back 2. Door 3. Roof side rail 4. Other ____________	Present? 1 2 3 4	Deployed? 1 2 UNK 3 4	Prior service? 1 2 UNK 3 4	Original Replacement 1 1 2 2 UNK 3 3 4 4
D. Second row right 1. Seat back 2. Door 3. Roof side rail 4. Other ____________	Present? 1 2 3 4	Deployed? 1 2 UNK 3 4	Prior service? 1 2 UNK 3 4	Original Replacement 1 1 2 2 UNK 3 3 4 4
E. Third row left 1. Seat back 2. Door 3. Roof side rail 4. Other ____________	Present? 1 2 3 4	Deployed? 1 2 UNK 3 4	Prior service? 1 2 UNK 3 4	Original Replacement 1 1 2 2 UNK 3 3 4 4
F. Third row right 1. Seat back 2. Door 3. Roof side rail 4. Other ____________	Present? 1 2 3 4	Deployed? 1 2 UNK 3 4	Prior service? 1 2 UNK 3 4	Original Replacement 1 1 2 2 UNK 3 3 4 4
I3. Has this vehicle: Been in previous crashes? No Unknown Yes (# of previous crashes____) If yes, did the airbag(s) deploy? No Unknown Yes (describe below) If yes, were airbag(s) reinstalled? No Unknown Yes (describe below)
I4. Is this vehicle equipped with an air bag shut off switch? No Unknown Yes – Auto Position Yes – Off Position Yes – Unknown Position
Describe any further air bag information or the presence of retrofitted air bags or shut off switches below.

J. INJURY INFORMATION
	DRIVER	OCCUPANT 2	OCCUPANT 3	OCCUPANT 4
J1. Was occupant injured? Yes No 3. Unknown	1 2 3	1 2 3	1 2 3	1 2 3
J2. Was occupant transported directly from crash scene for treatment? Yes No Unknown	1 2 3	1 2 3	1 2 3	1 2 3
J3. Did occupant receive any medical treatment? No EMS at scene Hospital Medical clinic Doctor’s office Treated by self Unknown	If 2, 3, 4, or 5 is selected, record medical facility information on the cover page.
	1 2 3 4 5 6 7	1 2 3 4 5 6 7	1 2 3 4 5 6 7	1 2 3 4 5 6 7
J4. IF HOSPITAL MARKED IN J3, Which describes occupant’s treatment level? Treated and released from emergency room Admitted to hospital (indicate number of days) Unknown	1 2 _________ 3	1 2 _________ 3	1 2 _________ 3	1 2 _________ 3
J5. Did occupant receive any follow-up treatment? Yes No 3. Unknown	If yes for any occupant(s) below, indicate additional treatment facilities on the cover page and any additional injuries diagnosed on the mannequins.
	1 2 3	1 2 3	1 2 3	1 2 3
J6. Did occupant miss any days of work or school as a result of the crash? (Includes full-time college student) Yes (write in number of days) No Not working prior to crash Unknown	1 __________ 2 3 4	1 __________ 2 3 4	1 __________ 2 3 4	1 __________ 2 3 4
J7. Need appointment to sign medical release? (If yes, record date and logistics on cover sheet) Yes No Unknown	If yes for any occupant(s) below, record the date, time and place to sign the medical release on the cover page.
	1 2 3	1 2 3	1 2 3	1 2 3

K. INDIVIDUAL INJURY DESCRIPTION

K1. Identify which occupant is being reported on here:

PSU Number ___ ___ Case Number—Stratum ___ ___ ___ ___ Vehicle Number ___ ___ Occupant Number ___ ___

K2. Did occupant have any of the following injuries?

Cuts Abrasions Bruises Fractures Head/skull/brain Internal Sprains/strains Other

Annotate Injury, Source, Body Region, and Aspect on the mannequins.

FRONT

BACK

RIGHT

LEFT

LEFT

RIGHT

K. INDIVIDUAL INJURY DESCRIPTION

K3. Identify which occupant is being reported on here:

PSU Number ___ ___ Case Number—Stratum ___ ___ ___ ___ Vehicle Number ___ ___ Occupant Number ___ ___

K4. Did occupant have any of the following injuries?

Cuts Abrasions Bruises Fractures Head/skull/brain Internal Sprains/strains Other

Annotate Injury, Source, Body Region, and Aspect on the mannequins.

FRONT

BACK

RIGHT

LEFT

LEFT

RIGHT

K. INDIVIDUAL INJURY DESCRIPTION

K5. Identify which occupant is being reported on here:

PSU Number ___ ___ Case Number—Stratum ___ ___ ___ ___ Vehicle Number ___ ___ Occupant Number ___ ___

K6. Did occupant have any of the following injuries?

Cuts Abrasions Bruises Fractures Head/skull/brain Internal Sprains/strains Other

Annotate Injury, Source, Body Region, and Aspect on the mannequins.

FRONT

BACK

RIGHT

LEFT

LEFT

RIGHT

K. INDIVIDUAL INJURY DESCRIPTION

K7. Identify which occupant is being reported on here:

PSU Number ___ ___ Case Number—Stratum ___ ___ ___ ___ Vehicle Number ___ ___ Occupant Number ___ ___

K8. Did occupant have any of the following injuries?

Cuts Abrasions Bruises Fractures Head/skull/brain Internal Sprains/strains Other

Annotate Injury, Source, Body Region, and Aspect on the mannequins.

FRONT

BACK

RIGHT

LEFT

LEFT

RIGHT

This page intentionally left blank.