NHTSA Form 1280 Supplemental Interview Form

Crash Investigation Sampling System: Supplemental Interview Form   

OMB Control Number: 2127-0706
Expiration Date: 07/31/2018

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

OCCUPANT 7

Front

2 3
5 6
8 9
Other

1
4
7

OCCUPANT 8

Front

2 3
5 6
8 9
Other

1
4
7

Front

2 3
5 6
8 9
Other

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)
A5. 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
A6. 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. ___________

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

Yes (Describe)

Yes (Describe)

Yes (Describe)

Yes (Describe)

No

No

No

No

A7. Occupant wearing glasses or have any
objects in mouth/hand? (Mark if Yes and
describe)
Unk

Unk

Unk

NHTSA Form 1280 (12/2017)
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.

Unk

Crash Investigation Sampling System: Supplemental Interview Form   

OMB Control Number: 2127-0706
Expiration Date: 07/31/2018

P a g e  | 2 
B. RESTRAINT INFORMATION
OCCUPANT 5
OCCUPANT 6
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
B4. Was there an upper anchorage
adjustment for the seat belt? (If yes,
indicate position)
1. No
2. Yes, full up
3. Yes, mid position
4. Yes, full down
5. Unknown
B5. Belt position for lap belt:
1. Snug and low across hips
2. Across abdomen
3. Low across hips with extra “slack”
4. Across abdomen with extra “slack”
5. Other position (specify)
6. Unknown position
B6. Belt position for shoulder belt:
1. Snug across collarbone and over
shoulder
2. Resting on neck
3. On edge of shoulder
4. Under arm
5. Behind occupants back or seat
6. Other position (specify)
7. Unknown belt position
Was there any “slack room” in the belt?

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

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

4

4

4

4

5

5

5

5

6

6

6

6

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

Yes
Unk

B7 Seating posture
1. Upright- back against seatback
2. Leaning forward
3. Leaning to the left
4. Leaning to the right
5. Lying across seat
6. Other (describe)
7. Unknown

OCCUPANT 7

No

Yes
Unk

No

Yes
Unk

No

Yes
Unk

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

NHTSA Form 1280 (12/2017)
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.

No

Crash Investigation Sampling System: Supplemental Interview Form   

OMB Control Number: 2127-0706
Expiration Date: 07/31/2018

P a g e  | 3 
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 (12/2017)
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: 2127-0706
Expiration Date: 07/31/2018

P a g e  | 4 
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
D5. Did occupant miss any days of
work or school as a result of the
crash? (Includes full-time college student)
1. Yes (write in number of days)
2. No
3. Not working prior to crash
4. Unknown

1

1

OCCUPANT 7
1

OCCUPANT 8
1

2

2

2

2

3

3

3

3

1

1

1

1

2

2

2

2

3

3

3

3

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

1 _________

1 _________

1 _________

1 _________

2

2

2

2

3

3

3

3

4

4

4

4

NHTSA Form 1280 (12/2017)
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: 2127-0706
Expiration Date: 07/31/2018

P a g e  | 5 
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

Annotate Injury, Location and Source

FRONT

No Injuries

LEFT

RIGHT

LEFT

RIGHT

BACK
NHTSA Form 1280 (12/2017)
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.

Other

Crash Investigation Sampling System: Supplemental Interview Form   

OMB Control Number: 2127-0706
Expiration Date: 07/31/2018

P a g e  | 6 
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

Annotate Injury, Location and Source

No Injuries

FRONT

LEFT

RIGHT

LEFT

RIGHT

BACK
NHTSA Form 1280 (12/2017)
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.

Other

Crash Investigation Sampling System: Supplemental Interview Form   

OMB Control Number: 2127-0706
Expiration Date: 07/31/2018

P a g e  | 7 
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

Annotate Injury, Location and Source

FRONT

No Injuries

LEFT

RIGHT

LEFT

RIGHT

BACK
NHTSA Form 1280 (12/2017)
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.

Other

Crash Investigation Sampling System: Supplemental Interview Form   

OMB Control Number: 2127-0706
Expiration Date: 07/31/2018

P a g e  | 8 
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

Annotate Injury, Location and Source

FRONT

No Injuries

LEFT

RIGHT

LEFT

RIGHT

BACK
NHTSA Form 1280 (12/2017)
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.

Other