NHTSA Form 1280 Supplemental Interview Form

Crash Investigation Sampling System: Supplemental Interview Form   

OMB Control Number xxxx-xxxx
Expiration Date xx/xx/xxxx

P a g e  | 1 
A. OCCUPANT DATA QUESTIONS
A1. 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

OCCUPANT 5

OCCUPANT 6

Front

A2. Seating position (Circle appropriate
position of each occupant)
If “Other” location, specify ______________
A3. Sex
1. Male
2. Female, not pregnant
3. Female, Pregnant, # of months
4. Female, unknown if pregnant

1
4
7

2 3
5 6
8 9
Other

OCCUPANT 7

Front

1
4
7

2 3
5 6
8 9
Other

OCCUPANT 8

Front

1
4
7

2 3
5 6
8 9
Other

Front

1
4
7

2 3
5 6
8 9
Other

1

1

1

1

2

2

2

2

3 __________

3 __________

3 __________

3 __________

4

4

4

4

If pregnant, indicate any crash related fetal complications on the
mannequin page
A4. Height, Weight, Age
1. Height (Feet and inches)
2. Weight (Pounds)
3. Age (Years)

B1. Was this occupant in a child safety
seat? (If yes, complete separate Interview
Form – Child Restraints)
B2. Type of seat belt available
1. Lap belt
2. Shoulder belt
3. Lap and shoulder belt
4. Not available (describe reason)
5. Unknown
B3. Occupant wearing any seatbelt?
1. Yes
2. No
3. Unknown

1. ___________
2. ___________
3. ___________

1. ___________
2. ___________
3. ___________

1. ___________
2. ___________
3. ___________

1. ___________
2. ___________
3. ___________

B. RESTRAINT INFORMATION
OCCUPANT 5
OCCUPANT 6

OCCUPANT 7

OCCUPANT 8

Yes
No

Yes
No

Yes
No

Yes
No

1

1

1

1

2

2

2

2

3

3

3

3

4 __________

4 __________

4 __________

4 __________

5

5

5

5

1

1

1

1

2

2

2

2

3

3

3

3

NHTSA Form 1280 (1/2015)
These reports are authorized by P.L. 89-563, Title 1, Section 106, 108, and 112. While you are not required to respond, your
cooperation is needed to make the results of this data collection effort comprehensive, accurate, and timely.

Crash Investigation Sampling System: Supplemental Interview Form   

OMB Control Number xxxx-xxxx
Expiration Date xx/xx/xxxx

P a g e  | 2 
C. EJECTION, ENTRAPMENT, MOBILITY INFORMATION
OCCUPANT 5
OCCUPANT 6
OCCUPANT 7
C1. Any part of body thrown outside the
vehicle during the crash?
1. No
1
1
1
2. Unknown
2
2
2
3. Yes (describe parts of body
3 (describe)
3 (describe)
3 (describe)
ejected and what area of vehicle
was involved)
C2. Was occupant physically pinned in the
vehicle?
1. No
1
1
1
2. Unknown
2
2
2
3. Yes (describe entrapment)
3 (describe)
3 (describe)
3 (describe)

C3. Was occupant trapped (but not pinned)
in the vehicle?
1. No
2. Unknown
3. Yes (describe entrapment)

C4. How did occupant exit the vehicle?
1. Fatal before removed
2. Removed while unconscious or not
oriented to time or place
3. Removed due to perceived serious
injuries
4. Exited with some assistance
5. Exited under own power
6. Fully ejected
7. Removed for other reasons
(specify)
8. Unknown

OCCUPANT 8

1
2
3 (describe)

1
2
3 (describe)

1

1

1

1

2

2

2

2

3 (describe)

3 (describe)

3 (describe)

3 (describe)

1

1

1

1

2

2

2

2

3

3

3

3

4

4

4

4

5

5

5

5

6

6

6

6

7

7

7

7

8

8

8

8

Further describe any ejection, entrapment or mobility information here.

NHTSA Form 1280 (1/2015)
These reports are authorized by P.L. 89-563, Title 1, Section 106, 108, and 112. While you are not required to respond, your
cooperation is needed to make the results of this data collection effort comprehensive, accurate, and timely.

Crash Investigation Sampling System: Supplemental Interview Form   

OMB Control Number xxxx-xxxx
Expiration Date xx/xx/xxxx

P a g e  | 3 
D. INJURY INFORMATION
OCCUPANT 5
OCCUPANT 6
D1. Was occupant injured?
1. Yes
2. No
3. Unknown
D2. Was occupant transported directly
from crash scene for treatment?
1. Yes
2. No
3. Unknown
D3. Did occupant receive any medical
treatment?
1.
2.
3.
4.
5.
6.
7.

No
EMS at scene
Hospital
Medical clinic
Doctor’s office
Treated by self
Unknown

D4. IF HOSPITAL MARKED IN D3,
Which describes occupant’s treatment
level?
1. Treated and released from
emergency room
2. Admitted to hospital (indicate
number of days)
3. Unknown

OCCUPANT 7

OCCUPANT 8

1

1

1

2

2

2

2

3

3

3

3

1

1

1

1

2

2

2

2

3

3

3

3

1

If 2, 3, 4, or 5 is selected, record medical facility information on the cover
page.
1

1

1

1

2

2

2

2

3

3

3

3

4

4

4

4

5

5

5

5

6

6

6

6

7

7

7

7

1

1

1

1

2 _________

2 _________

2 _________

2 _________

3

3

3

3

NHTSA Form 1280 (1/2015)
These reports are authorized by P.L. 89-563, Title 1, Section 106, 108, and 112. While you are not required to respond, your
cooperation is needed to make the results of this data collection effort comprehensive, accurate, and timely.

Crash Investigation Sampling System: Supplemental Interview Form   

OMB Control Number xxxx-xxxx
Expiration Date xx/xx/xxxx

P a g e  | 4 
E. INDIVIDUAL INJURY DESCRIPTION
E1. Identify which occupant is being reported on here:
PSU Number ___ ___ Case Number ___ ___ ___ ___ Vehicle Number ___ ___ Occupant Number ___ ___
E2. Did occupant have any of the following injuries?
Cuts
Abrasions
Bruises
Fractures
Head/skull/brain

Internal

Sprains/strains

Other

Annotate Injury, Location and Source

FRONT

No Injuries

LEFT

RIGHT

LEFT

RIGHT

BACK
NHTSA Form 1280 (1/2015)
These reports are authorized by P.L. 89-563, Title 1, Section 106, 108, and 112. While you are not required to respond, your
cooperation is needed to make the results of this data collection effort comprehensive, accurate, and timely.

Crash Investigation Sampling System: Supplemental Interview Form   

OMB Control Number xxxx-xxxx
Expiration Date xx/xx/xxxx

P a g e  | 5 
E. INDIVIDUAL INJURY DESCRIPTION
E3. Identify which occupant is being reported on here:
PSU Number ___ ___ Case Number ___ ___ ___ ___ Vehicle Number ___ ___ Occupant Number ___ ___
E4. Did occupant have any of the following injuries?
Cuts
Abrasions
Bruises
Fractures
Head/skull/brain

Internal

Sprains/strains

Other

Annotate Injury, Location and Source

FRONT

No Injuries

LEFT

RIGHT

LEFT

RIGHT

BACK
NHTSA Form 1280 (1/2015)
These reports are authorized by P.L. 89-563, Title 1, Section 106, 108, and 112. While you are not required to respond, your
cooperation is needed to make the results of this data collection effort comprehensive, accurate, and timely.

Crash Investigation Sampling System: Supplemental Interview Form   

OMB Control Number xxxx-xxxx
Expiration Date xx/xx/xxxx

P a g e  | 6 
E. INDIVIDUAL INJURY DESCRIPTION
E5. Identify which occupant is being reported on here:
PSU Number ___ ___ Case Number ___ ___ ___ ___ Vehicle Number ___ ___ Occupant Number ___ ___
E6. Did occupant have any of the following injuries?
Cuts
Abrasions
Bruises
Fractures
Head/skull/brain

Internal

Sprains/strains

Other

Annotate Injury, Location and Source

FRONT

No Injuries

LEFT

RIGHT

LEFT

RIGHT

BACK
NHTSA Form 1280 (1/2015)
These reports are authorized by P.L. 89-563, Title 1, Section 106, 108, and 112. While you are not required to respond, your
cooperation is needed to make the results of this data collection effort comprehensive, accurate, and timely.

Crash Investigation Sampling System: Supplemental Interview Form   

OMB Control Number xxxx-xxxx
Expiration Date xx/xx/xxxx

P a g e  | 7 
E. INDIVIDUAL INJURY DESCRIPTION
E7. Identify which occupant is being reported on here:
PSU Number ___ ___ Case Number ___ ___ ___ ___ Vehicle Number ___ ___ Occupant Number ___ ___
E8. Did occupant have any of the following injuries?
Cuts
Abrasions
Bruises
Fractures
Head/skull/brain

Internal

Sprains/strains

Other

Annotate Injury, Location and Source

FRONT

No Injuries

LEFT

RIGHT

LEFT

RIGHT

BACK
NHTSA Form 1280 (1/2015)
These reports are authorized by P.L. 89-563, Title 1, Section 106, 108, and 112. While you are not required to respond, your
cooperation is needed to make the results of this data collection effort comprehensive, accurate, and timely.