NHTSA Form 1279 Interview Form

OMB Control Number: 2127-0706
Expiration Date: 07/31/2018
U.S. Department of Transportation
National Highway Traffic Safety Administration

1. Primary Sampling Unit Number
2. Case Number

INTERVIEW FORM (A)
___ ___
___ ___ ___ ___

3. Vehicle Number

CRASH INVESTIGATION SAMPLING SYSTEM

Interviewee(s) Role: ________________________________
_________________________________________________

___ ___
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.)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

NHTSA Form 1279 (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: Interview Form

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

Page 2

A. CRASH DATA INFORMATION
IF POSSIBLE, OBTAIN THIS INFORMATION FROM THE DRIVER
A1. Avoidance actions (Mark
all that apply)

None
Accelerating
Unknown
Other (describe)

Braking
Steering left

Releasing brakes
Steering right

Use this space for any additional notes about the pre-crash and impact.

B. ROLLOVER INFORMATION
Left side
Top

B1. Plane in contact with
ground at final rest

Right side
Wheels

Unknown

C. DRIVER ACTIONS

C1. 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:

D. ADDITIONAL VEHICLE INFORMATION
No
Unknown
Yes (describe)

D1. Cargo in the vehicle
(Describe any objects in the
vehicle or trunk)

Approximate weight of cargo: _____ pounds
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.

D2. Location of vehicle

Vehicle inspected
Vehicle location recorded on cover sheet
Insurance information recorded on cover sheet

Ask questions D3 – D5 for 2010 and newer vehicles only
D3. Is the vehicle equipped
with any of the following
features? (Mark all that apply)

NHTSA Form 1279 (12/2017)

Lane Keeping Support
Lane Departure Warning
Crash Imminent Braking
Forward Collision Warning
Blind Spot Detection
Automatic Crash Notification

Daytime Running Light
Rearview Video System
Dynamic Brake Support
Pedestrian Automatic Emergency Braking
Advanced Lighting
Adaptive Cruise Control

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: Interview Form

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

Page 3

D. ADDITIONAL VEHICLE INFORMATION (continued)
D4. Were any of the avoidance
features (listed in D3) disabled
at the time of the crash?

D5. Did occupants see, hear,
or feel anything to indicate
activation of the above
features?

No
Unknown
Yes (describe)
No
Unknown
Yes (describe)

E. OCCUPANT DATA QUESTIONS
E1. 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

Front

E2. Seating position (Circle appropriate
position of each occupant)
If “Other” location, specify ______________
E3. Sex
1. Male
2. Female, not pregnant
3. Female, Pregnant, # of months
4. Female, unknown if pregnant

1
4
7

OCCUPANT 3

Front

2 3
5 6
8 9
Other

1
4
7

OCCUPANT 4

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
E4. Height, Weight, Age
1. Height (Feet and inches)
2. Weight (Pounds)
3. Age (Years)
E5. 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
E6. 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

E7. Occupant wearing glasses or have any
objects in mouth/hand? (Mark if Yes and
describe)

NHTSA Form 1279 (12/2017)

Unk

Unk

Unk

Unk

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: Interview Form

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

Page 4

F. RESTRAINT INFORMATION
DRIVER
OCCUPANT 2
F1. Was this occupant in a child safety
seat? (If yes, complete separate Interview
Form – Child Restraints)
F2. Type of seat belt available
1. Lap belt
2. Shoulder belt
3. Lap and shoulder belt
4. Not available (describe reason)
5. Unknown
F3. Occupant wearing any seatbelt?
1. Yes
2. No
3. Unknown
F4. 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
F5. 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
F6. 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?

NHTSA Form 1279 (12/2017)

OCCUPANT 4

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

F7 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 3

No

Yes
Unk

No

Yes
Unk

No

Yes

No

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

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: Interview Form

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

Page 5

G. EJECTION, ENTRAPMENT, MOBILITY INFORMATION
DRIVER
G1. Any part of body thrown outside the
vehicle during the crash?
1. No
2. Unknown
3. Yes (describe parts of body
ejected and what area of vehicle
was involved)
G2. Was occupant physically pinned in the
vehicle?
1. No
2. Unknown
3. Yes (describe entrapment)
G3. Was occupant trapped (but not pinned)
in the vehicle?
1. No
2. Unknown
3. Yes (describe entrapment)
G4. 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 2

OCCUPANT 3

OCCUPANT 4

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 (describe)

3 (describe)

3 (describe)

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 1279 (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: Interview Form

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

Page 6

H. AIR BAG INFORMATION
H1. 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 I)

Unknown (SKIP TO SECTION I)

H2. Is this vehicle equipped with an air bag shut off switch?
No

Unknown

Yes – Auto Position

Yes – Off Position

Yes – Unknown Position

H3. 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)

Had prior maintenance/service on air bag?

No

Unknown

Yes (describe below)

H4. Type of air bag:
Original manufacturer installed
Replacement air bag
Retrofitted air bag
Unknown

Describe any further air bag information or the presence of retrofitted air bags or shut off switches below.

NHTSA Form 1279 (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: Interview Form

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

Page 7

I. INJURY INFORMATION
DRIVER
OCCUPANT 2
I1. Was occupant injured?
1. Yes
2. No
3. Unknown
I2. Was occupant transported directly
from crash scene for treatment?
1. Yes
2. No
3. Unknown
I3. 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

I4. IF HOSPITAL MARKED IN I3, Which
describes occupant’s treatment level?
1. Treated and released from
emergency room
2. Admitted to hospital (indicate
number of days)
3. Unknown
I5. 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

NHTSA Form 1279 (12/2017)

OCCUPANT 3

OCCUPANT 4

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

1 _________

1 _________

1 _________

1 _________

2

2

2

2

3

3

3

3

4

4

4

4

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: Interview Form

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

Page 8

J. INDIVIDUAL INJURY DESCRIPTION
J1. Identify which occupant is being reported on here:
PSU Number ___ ___ Case Number ___ ___ ___ ___ Vehicle Number ___ ___ Occupant Number ___ ___
J2. 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

RIGHT

LEFT

LEFT

RIGHT

BACK
NHTSA Form 1279 (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: Interview Form

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

Page 9

J. INDIVIDUAL INJURY DESCRIPTION
J3. Identify which occupant is being reported on here:
PSU Number ___ ___ Case Number ___ ___ ___ ___ Vehicle Number ___ ___ Occupant Number ___ ___
J4. 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

RIGHT

LEFT

LEFT

RIGHT

BACK
NHTSA Form 1279 (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: Interview Form

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

Page 10

J. INDIVIDUAL INJURY DESCRIPTION
J5. Identify which occupant is being reported on here:
PSU Number ___ ___ Case Number ___ ___ ___ ___ Vehicle Number ___ ___ Occupant Number ___ ___
J6. 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

RIGHT

LEFT

LEFT

RIGHT

BACK
NHTSA Form 1279 (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: Interview Form

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

Page 11

J. INDIVIDUAL INJURY DESCRIPTION
J7. Identify which occupant is being reported on here:
PSU Number ___ ___ Case Number ___ ___ ___ ___ Vehicle Number ___ ___ Occupant Number ___ ___
J8. 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

RIGHT

LEFT

LEFT

RIGHT

BACK
NHTSA Form 1279 (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.