NHTSA Form 1667 FARS Data Entry Form

OMB Control No. 2127-0006

Expiration Date XX/XX/XXXX

2021 Fatality Analysis Reporting System

CRASH LEVEL

This collection of information is voluntary and will be used for informative purposes only so that we may develop and evaluate programs designed to reduce the number of motor vehicle-related injuries and deaths. We will not collect any personal information that would allow anyone to identify you. 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 2127-0006. Public reporting for this collection of information is estimated to be approximately 3 hours per response, including the time for reviewing instructions, completing and reviewing the collection of information. All responses to this collection of information are voluntary. 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, W51-316, 1200 New Jersey Ave, S.E., Washington, DC, 20590

State Number Consecutive Number **Number of Forms Submitted for Persons Not in Motor Vehicles **Number of Vehicle Submitted

**Number of Motor Vehicle Occupant Forms Submitted State Case #

Crash Date / / 2021			Crash Time :
County			City
Relation To Junction: Within Interchange Area			Relation To Junction: Specific Location
0 - No			01 - Non-Junction
1 - Yes			02 - Intersection
8 - Not Reported			03 - Intersection-Related
9 - Reported as Unknown			04 - Driveway Access
			05 - Entrance/Exit Ramp Related
			06 - Railway Grade Crossing
			07 - Crossover-Related
			08 - Driveway Access Related
			16 - Shared-Use Path Crossing
			17 - Acceleration/Deceleration Lane
			18 - Through Roadway
			19 - Other location within interchange area
			20 - Entrance/Exit Ramp
			98 - Not Reported
			99 - Reported as Unknown
Type of Intersection			Relation to Trafficway
01 - Not an Intersection			01 - On Roadway
02 - Four-Way Intersection			02 - On Shoulder
03 - T-Intersection			03 - On Median
04 - Y-Intersection			04 - On Roadside
05 - Traffic Circle			05 - Outside Trafficway
06 - Roundabout			06 - Off Roadway-Location Unknown
07 - Five Point, or More			07 - In Parking Lane/Zone
10 - L-Intersection			08 - Gore
11 - Other Intersection Type			10 - Separator
98 - Not Reported			11 - Continuous Left - Turn Lane
99 - Reported as Unknown			12 - Pedestrian Refuge Island or Traffic Island
			98 - Not Reported
			99 - Reported as Unknown

Work Zone			Light Condition
0 - None			1 - Daylight
1 - Construction			2 - Dark - Not Lighted
2 - Maintenance			3 - Dark - Lighted
3 - Utility			4 - Dawn
4 - Work Zone, Type Unknown			5 - Dusk
			6 - Dark - Unknown Lighting
			7 - Other
			8 - Not Reported
			9 - Reported as Unknown
Atmospheric Conditions
01 - Clear
02 - Rain
03 - Sleet or Hail
04 - Snow
05 - Fog, Smog, Smoke
06 - Severe Crosswinds
07 - Blowing Sand, Soil, Dirt
08 - Other
10 - Cloudy
11 - Blowing Snow
12 - Freezing Rain or Drizzle
98 - Not Reported
99 - Reported as Unknown

TRAFFICWAY - CRASH LEVEL

Trafficway Identifier (1)			Trafficway Identifier (2)
Route Signing			Land Use
1 - Interstate			1 - Rural
2 - U.S. Highway			2 - Urban
3 - State Highway			6 - Trafficway Not in State Inventory
4 - County Road			8 - Not Reported
5 - Local Street - Township			9 - Unknown
6 - Local Street - Municipality
7 - Local Street - Frontage Road
8 - Other
9 - Unknown
Functional System			Ownership
01 - Interstate			01 - State Highway Agency
02 - Principal Arterial - Other Freeways and Expressways			02 - County Highway Agency
03 - Principal Arterial - Other			03 - Town or Township Highway Agency
04 - Minor Arterial			04 - City or Municipal Highway Agency
05 - Major Collector			11 - State Park, Forest, or Reservation Agency
06 - Minor Collector			12 - Local Park, Forest or Reservation Agency
07 - Local			21 - Other State Agency
96 - Trafficway Not in State Inventory			25 - Other Local Agency
98 - Not Reported			26 - Private (other than Railroad)
99 - Unknown			27 - Railroad
			31 - State Toll Road
			32 - Local Toll Authority
			40 - Other Public Instrumentality (i.e., Airport)
			50 - Indian Tribe Nation
			60 - Other Federal Agency
			62 - Bureau of Indian Affairs
			63 - Bureau of Fish and Wildlife
			64 - U.S. Forest Service
			66 - National Park Service
			67 - Tennessee Valley Authority
			68 - Bureau of Land Management
			69 - Bureau of Reclamation
			70 - Corps of Engineers
			72 - Air Force
			74 - Navy/Marines
			80 - Army
			96 - Trafficway Not in State Inventory
			98 - Not Reported
			99 - Unknown

National Highway System					Special Jurisdiction
0 - This section IS NOT on the NHS					0 - No Special Jurisdiction
1 - This section IS ON the NHS					1 - National Park Service
9 - Unknown if this section is on the NHS					2 - Military
					3 - Indian Reservation
					4 - College/University Campus*
					5 - Other Federal Properties*
					8 - Other
					9 - Unknown
	Mile Point	.	Global Position Latitude: Longitude:			Deg	Min	Sec

OTHER - CRASH LEVEL

School Bus Related	Rail Grade Crossing Identifier
Notification Time EMS :	Arrival Time EMS :
EMS Time at Hospital :	Crash Related Factors
Additional State Information (1)	Additional State Information (2)

2021 Fatality Analysis Reporting System CRASH LEVEL - CRASH EVENTS

Click here to open Clock Point Diagrams

First Harmful Event

Manner of Collision of the First Harmful Event

2021 Fatality Analysis Reporting System PERSON LEVEL (NOT A MV OCCUPANT)

State Number Consecutive Number **Person Number

Vehicle Number of Motor Vehicle Striking Non-Motorist						Age
Sex			Person Type
1 - Male			04 - Occupant of a Non-Motor Vehicle Transport Device
2 - Female			05 - Pedestrian
8 - Not Reported			06 - Bicyclist
9 - Reported as Unknown			07 - Other Cyclist
			10 - Persons In/On Buildings
			11 - Person on Motorized Personal Conveyance
			12 - Person on Non-Motorized Personal Conveyance
			13 - Person on Personal Conveyance, Unknown if Motorized or Non- Motorized
			19 - Unknown Type of Non-Motorist
Injury Severity			Transported to First Medical Facility By
0 - No Apparent Injury (O)			0 - Not Transported for Treatment
1 - Possible Injury (C)			1 - EMS Air
2 - Suspected Minor Injury (B)			2 - Law Enforcement
3 - Suspected Serious Injury (A)			3 - EMS Unknown Mode
4 - Fatal Injury (K)			4 - Transported Unknown Source
5 - Injured, Severity Unknown			5 - EMS Ground
6 - Died Prior to Crash*			6 - Other
9 - Unknown/Not Reported			8 - Not Reported
			9 - Reported as Unknown
Non-Motorist Related Factors			Conditions at Time of Crash
			00 - None/Apparently Normal
			01 - Ill, Blackout
			02 - Asleep or Fatigued
			03 - Walking with a Cane or Crutches, etc.
			04 - Paraplegic or in a Wheelchair
			05 - Impaired Due to Previous Injury
			06 - Deaf/Hard of Hearing
			07 - Blind/Low Vision
			08 - Emotional (depressed, angry, disturbed, etc.)
			09 - Under the Influence of Alcohol, Drugs or Medication
			10 - Physical Impairment - No Details
			96 - Other Physical Impairment
			98 - Not Reported
			99 - Reported as Unknown if Impaired

2021 Fatality Analysis Reporting System PERSON LEVEL (NOT A MV OCCUPANT - PEDESTRIAN)

State Number Consecutive Number **Vehicle Number **Person Number

School Zone				Marked Crosswalk
0 - None Noted				0 - None Noted
1 - Yes				1 - Yes
9 - Unknown				9 - Unknown
Sidewalk Presence			Crash Type Number
0 - None Noted
1 - Yes
9 - Unknown
Crash Group Number				Crash Location
100 - Unusual Circumstances				1 - At Intersection
200 - Backing Vehicle				2 - Intersection-Related
310 - Working or Playing in Roadway				3 - Not At Intersection
340 - Bus Stop-Related				4 - Non-Trafficway Location
350 - Unique Midblock				9 - Unknown / Insufficient Information
400 - Walking/Running Along Roadway
460 - Driveway Access/Driveway Access Related
500 - Waiting to Cross
600 - Pedestrian in Roadway - Circumstances Unknown
720 - Multiple Threat / Trapped
740 - Dash – Run, No Visual Obstruction Noted / Dart-Out – Visual Obstruction Noted
750 - Crossing Roadway - Vehicle Not Turning
790 - Crossing Roadway - Vehicle Turning
800 - Non-Trafficway
910 - Crossing Expressway
990 - Other / Unknown - Insufficient Details
Pedestrian Position				Pedestrian Initial Direction of Travel
1 - Intersection Area				1 - Northbound
2 - Crosswalk Area				2 - Eastbound
3 - Travel Lane				3 - Southbound
4 - Paved Shoulder / Bicycle Lane / Parking Lane				4 - Westbound
5 - Sidewalk / Shared-Use Path / Driveway Access				9 - Not Derived/Unknown Initial Direction of Travel
6 - Unpaved Right-of-Way
7 - Non-Trafficway - Driveway
8 - Non-Trafficway - Parking Lot/Other
9 - Other/Unknown

1 - Northbound

1 - Left Turn

2 - Eastbound

2 - Right Turn

3 - Southbound

3 - Straight through

9 - Unknown Initial Direction of Travel

4 - Westbound

9 - Unknown Motorist Maneuver

Leg Intersection Scenario

1 - Nearside

_{2 -} Farside

₉ - Unknown/None of the Above

Crash Type Expanded

2021 Fatality Analysis Reporting System

NON-MOTORIST ACTIONS (NOT A MV OCCUPANT)

NM. Location at Time of Crash	NM. Action/Circumstances
NM. Contributing Circumstances	NM. Distracted By

Non-Motorist Safety Equipment

Protective
Helmet			Pads
1 - No			1 - No
2 - Yes			2 - Yes
8 - Not Reported			8 - Not Reported
9 - Reported as Unknown			9 - Reported as Unknown
Other
1 - No
2 - Yes
8 - Not Reported
9 - Reported as Unknown

Preventive
Clothing			Lighting
1 - No			1 - No
2 - Yes			2 - Yes
8 - Not Reported			8 - Not Reported
9 - Reported as Unknown			9 - Reported as Unknown
Other
1 - No
2 - Yes
8 - Not Reported
9 - Reported as Unknown

2021 Fatality Analysis Reporting System ALCOHOL (NOT A MV OCCUPANT)

Police-Reported Alcohol Involvement				Alcohol Test Status
0 - No (Alcohol Not Involved)				0 - Test Not Given
1 - Yes (Alcohol Involved)				2 - Test Given
8 - Not Reported				8 - Not Reported
9 - Reported as Unknown				9 - Reported as Unknown if Tested
Alcohol Test Type			Alcohol Test Result
00 - Test Not Given
01 - Blood
02 - Breath Test (AC)
03 - Urine
04 - Vitreous
05 - Blood Plasma/Serum
06 - Blood Clot
07 - Liver
08 - Other Test Type
10 - Preliminary Breath Test (PBT)
11 - Breath Test, Unknown Type
95 - Not Reported
98 - Unknown Test Type
99 - Reported as Unknown if Tested

DRUG (NOT A MV OCCUPANT)

Police Reported Drug Involvement				Method of Drug Determination by Police
Drug Test Status
Drug Toxicology Results Drug Specimen Drug Test Results

2021 Fatality Analysis Reporting System RACE (NOT A MV OCCUPANT)

SUPPLEMENTAL (NOT A MV OCCUPANT)

Died at Scene/En Route			Death Date / /
0 - Not Applicable
7 - Died at Scene
8 - Died En Route
9 - Unknown
Death Time :

2021 Fatality Analysis Reporting System PERSON LEVEL (NOT A MV OCCUPANT)

State Number Consecutive Number **Person Number

Vehicle Number of Motor Vehicle Striking Non-Motorist						Age
Sex			Person Type
1 - Male			04 - Occupant of a Non-Motor Vehicle Transport Device
2 - Female			05 - Pedestrian
8 - Not Reported			06 - Bicyclist
9 - Reported as Unknown			07 - Other Cyclist
			10 - Persons In/On Buildings
			11 - Person on Motorized Personal Conveyance
			12 - Person on Non-Motorized Personal Conveyance
			13 - Person on Personal Conveyance, Unknown if Motorized or Non- Motorized
			19 - Unknown Type of Non-Motorist
Injury Severity			Transported to First Medical Facility By
0 - No Apparent Injury (O)			0 - Not Transported for Treatment
1 - Possible Injury (C)			1 - EMS Air
2 - Suspected Minor Injury (B)			2 - Law Enforcement
3 - Suspected Serious Injury (A)			3 - EMS Unknown Mode
4 - Fatal Injury (K)			4 - Transported Unknown Source
5 - Injured, Severity Unknown			5 - EMS Ground
6 - Died Prior to Crash*			6 - Other
9 - Unknown/Not Reported			8 - Not Reported
			9 - Reported as Unknown
Non-Motorist Related Factors			Conditions at Time of Crash
			00 - None/Apparently Normal
			01 - Ill, Blackout
			02 - Asleep or Fatigued
			03 - Walking with a Cane or Crutches, etc.
			04 - Paraplegic or in a Wheelchair
			05 - Impaired Due to Previous Injury
			06 - Deaf/Hard of Hearing
			07 - Blind/Low Vision
			08 - Emotional (depressed, angry, disturbed, etc.)
			09 - Under the Influence of Alcohol, Drugs or Medication
			10 - Physical Impairment - No Details
			96 - Other Physical Impairment
			98 - Not Reported
			99 - Reported as Unknown if Impaired

2021 Fatality Analysis Reporting System PERSON LEVEL (NOT A MV OCCUPANT - BIKE)

State Number Consecutive Number **Vehicle Number **Person Number

School Zone

Marked Crosswalk

0 - None Noted

1 - Yes

9 - Unknown Sidewalk Presence

0 - None Noted

1 - Yes

9 - Unknown

0 - None Noted

1 - Yes

9 - Unknown

Crash Type Number

Crash Group Number

Crash Location

110 - Loss of Control / Turning Error

140 - Motorist Failed to Yield - Sign-Controlled Intersection 145 - Bicyclist Failed to Yield - Sign-Controlled Intersection 150 - Motorist Failed to Yield - Signalized Intersection

158 - Bicyclist Failed to Yield - Signalized Intersection 190 - Crossing Paths - Other Circumstances

210 - Motorist Left Turn / Merge 215 - Motorist Right Turn / Merge

219 - Parking / Bus-Related

220 - Bicyclist Left Turn / Merge 225 - Bicyclist Right Turn / Merge 230 - Motorist Overtaking Bicyclist 240 - Bicyclist Overtaking Motorist 258 - Wrong-Way / Wrong-Side

290 - Parallel Paths - Other Circumstances 310 - Bicyclist Failed to Yield - Midblock 320 - Motorist Failed to Yield - Midblock 600 - Backing Vehicle

850 - Other / Unusual Circumstances 910 - Non-Trafficway

990 - Other / Unknown - Insufficient Details Bicyclist Position

1 - At Intersection

2 - Intersection-Related

3 - Not At Intersection

4 - Non-Trafficway Location

9 - Unknown / Insufficient Information

Bicyclist Direction

1. - Travel Lane

2. - Bicycle Lane / Paved Shoulder / Parking Lane

3. - Sidewalk / Crosswalk / Driveway Access

4. - Shared-Use Path

5. - Non-Trafficway - Driveway

6. - Non-Trafficway - Parking Lot/Other

8. - Other

9. - Unknown

Crash Type Expanded

1. - With Traffic

2. - Facing Traffic

3 - Not applicable

_{9 -} Unknown

2021 Fatality Analysis Reporting System

NON-MOTORIST ACTIONS (NOT A MV OCCUPANT)

NM. Location at Time of Crash	NM. Action/Circumstances
NM. Contributing Circumstances	NM. Distracted By

Non-Motorist Safety Equipment

Protective
Helmet			Pads
1 - No			1 - No
2 - Yes			2 - Yes
8 - Not Reported			8 - Not Reported
9 - Reported as Unknown			9 - Reported as Unknown
Other
1 - No
2 - Yes
8 - Not Reported
9 - Reported as Unknown

Preventive
Clothing			Lighting
1 - No			1 - No
2 - Yes			2 - Yes
8 - Not Reported			8 - Not Reported
9 - Reported as Unknown			9 - Reported as Unknown
Other
1 - No
2 - Yes
8 - Not Reported
9 - Reported as Unknown

2021 Fatality Analysis Reporting System ALCOHOL (NOT A MV OCCUPANT)

Police-Reported Alcohol Involvement				Alcohol Test Status
0 - No (Alcohol Not Involved)				0 - Test Not Given
1 - Yes (Alcohol Involved)				2 - Test Given
8 - Not Reported				8 - Not Reported
9 - Reported as Unknown				9 - Reported as Unknown if Tested
Alcohol Test Type			Alcohol Test Result
00 - Test Not Given
01 - Blood
02 - Breath Test (AC)
03 - Urine
04 - Vitreous
05 - Blood Plasma/Serum
06 - Blood Clot
07 - Liver
08 - Other Test Type
10 - Preliminary Breath Test (PBT)
11 - Breath Test, Unknown Type
95 - Not Reported
98 - Unknown Test Type
99 - Reported as Unknown if Tested

DRUG (NOT A MV OCCUPANT)

Police Reported Drug Involvement				Method of Drug Determination by Police
Drug Test Status
Drug Toxicology Results Drug Specimen Drug Test Results

2021 Fatality Analysis Reporting System RACE (NOT A MV OCCUPANT)

SUPPLEMENTAL (NOT A MV OCCUPANT)

Died at Scene/En Route			Death Date / /
0 - Not Applicable
7 - Died at Scene
8 - Died En Route
9 - Unknown
Death Time :

2021 Fatality Analysis Reporting System VEHICLE LEVEL # 1

State Number Consecutive Number **Vehicle Number **Number Of Occupants

Number of Occupants				Unit Type
				1 - Motor Vehicle In-Transport (Inside or Outside the Trafficway)
				2 - Motor Vehicle Not In-Transport Within the Trafficway
				3 - Motor Vehicle Not In-Transport Outside the Trafficway
				4 - Working Motor Vehicle (Highway Construction, Maintenance, Utility only)
Hit and Run			Registration State
0 - No
1 - Yes
Registered Vehicle Owner			Travel Speed
0 - Not Applicable, Vehicle Not Registered
1 - Driver (in this crash) was Registered Owner
2 - Driver (in this crash) Not Registered Owner (Other Private Owner Listed)
3 - Vehicle Registered as Commercial/Business/Company/Government Vehicle
4 - Vehicle Registered as Rental Vehicle
5 - Vehicle was Stolen (reported by police)
6 - Driverless/Motor Vehicle Parked/Stopped Off Roadway
9 - Unknown
Vehicle Underride/Override				Rollover
0 - No Underride or Override				0 - No Rollover
1 - Underride				1 - Rollover, Tripped by Object/Vehicle
2 - Override				2 - Rollover, Untripped
7 - Not Applicable				9 - Rollover, Unknown Type
8 - Not Reported
9 - Reported as Unknown

Location of Rollover				Areas of Impact-Initial
0 - No Rollover				00 - Non-Collision
1 - On Roadway				01 - 1 Clock Point
2 - On Shoulder				02 - 2 Clock Point
3 - On Median/Separator				03 - 3 Clock Point
4 - In Gore				04 - 4 Clock Point
5 - On Roadside				05 - 5 Clock Point

6 - Outside of Trafficway				06 - 6 Clock Point
7 - In Parking Lane/Zone				07 - 7 Clock Point
9 - Unknown				08 - 8 Clock Point
				09 - 9 Clock Point
				10 - 10 Clock Point
				11 - 11 Clock Point
				12 - 12 Clock Point
				13 - Top
				14 - Undercarriage
				18 - Cargo/Vehicle Parts Set-In-Motion
				19 - Other Objects or Person Set-In-Motion
				20 - Object Set in Motion, Unknown if Cargo/Vehicle Parts or Other
				61 - Left
				62 - Left-Front Side
				63 - Left-Back Side
				81 - Right
				82 - Right-Front Side
				83 - Right-Back Side
				98 - Not Reported
				99 - Reported as Unknown
Extent of Damage				Vehicle Removal
0 - No Damage				2 - Towed Due to Disabling Damage
2 - Minor Damage				3 - Towed But Not Due to Disabling Damage
4 - Functional Damage				5 - Not Towed
6 - Disabling Damage				7 - Towed, Unknown Reason
8 - Not Reported				8 - Not Reported
9 - Reported as Unknown				9 - Reported as Unknown
Vehicle Sequence of Events			Most Harmful Event

DAMAGED AREAS FOR VEHICLE# 1

VIN INFORMATION FOR VEHICLE# 1

Vehicle Model Year	VIN 00000000000000000 - No VIN Required, Not a Vehicle for Road Use 88888888888888888 - Not Reported 99999999999999999 - Reported as Unknown
vPIC Make	vPIC Model
vPIC Body Class	NCSA Make
NCSA Model	NCSA Body Type
Power Unit GVWR From	Power Unit GVWR To
Automation System(s) in Vehicle Highest Automation System Level Present in Vehicle Highest Automation System Level Engaged at Time of Crash

DETAILS FOR VEHICLE# 1

Motor Carrier ID Issuing Authority Motor Carrier Identification Number						Vehicle Configuration
						00 - Not Applicable
						01 - Single-Unit Truck (2- axle and GVWR more than 10,000 lbs)
						02 - Single-Unit Truck (3 or more axles)
						04 - Truck Pulling Trailer(s)
						05 - Truck Tractor (Bobtail)
						06 - Truck Tractor/Semi-Trailer
						07 - Truck Tractor/Double
						08 - Truck Tractor/Triple
						10 - Vehicle 10,000 pounds or less placarded for hazardous materials
						19 - Vehicle More Than 10,000 lbs., Other
						20 - Bus/Large Van (seats for 9-15 occupants, including driver)
						21 - Bus (seats for more than 15 occupants, including driver)
						88 - Qualifying Vehicle, Unknown Configuration
						99 - Unknown
	Cargo Body Type				HM1: Hazardous Material Involvement
	00 - Not Applicable (N/A)				1 - No
	01 - Van/Enclosed Box				2 - Yes
	02 - Cargo Tank				HM2: Placard
	03 - Flatbed
	04 - Dump
	05 - Concrete Mixer				0 - Not Applicable
	06 - Auto Transporter				1 - No
	07 - Garbage/Refuse				2 - Yes
	08 - Grain/ Chips/ Gravel				8 - Not Reported
	09 - Pole-Trailer				HM3: Hazardous Material ID Number
	10 - Log
	11 - Intermodal Container Chassis
					0000 - Not Applicable
	12 - Vehicle Towing Another Motor Vehicle
					8888 - Not Reported
	22 - Bus
					HM4: Hazardous Material Class Number
	96 - No Cargo Body Type
	97 - Other
	98 - Unknown Cargo Body Type
					00 - Not Applicable
	99 - Unknown
					01 - 01
					02 - 02
					03 - 03
					04 - 04
					05 - 05
					06 - 06
					07 - 07
					08 - 08
					09 - 09
					88 - Not Reported
					HM5: Release of Hazardous Material from the Cargo Compartment
					0 - Not Applicable
					1 - No
					2 - Yes
					8 - Not Reported

OTHER INFORMATION FOR VEHICLE# 1

Vehicle Trailing				Jackknife
0 - No Trailing Units				0 - Not an Articulated Vehicle
1 - One Trailing Unit				1 - No
2 - Two Trailing Units				2 - Yes - First Event
3 - Three or More Trailing Units				3 - Yes - Subsequent Event
4 - Yes, Number of Trailing Units Unknown
5 - Vehicle Towing Another Motor Vehicle - Fixed Linkage
6 - Vehicle Towing Another Motor Vehicle - Non-Fixed Linkage
9 - Unknown
Bus Use				Special Use
00 - Not a Bus				00 - No Special Use Noted
01 - School				01 - Taxi
04 - Intercity				02 - Vehicle Used for School Transport
05 - Charter/Tour				03 - Vehicle Used as Other Bus
06 - Transit/ Commuter				04 - Military
07 - Shuttle				05 - Police
08 - Modified for Personal/Private Use				06 - Ambulance
98 - Not Reported				07 - Fire Truck
99 - Reported as Unknown				08 - Non-Transport Emergency Services Vehicle
				10 - Safety Service Patrols – Incident Response
				11 - Other Incident Response
				12 - Towing – Incident Response
				19 - Motor Vehicle Used for Vehicle Sharing Mobility
				20 - Motor Vehicle Used for Electronic Ride-hailing
				21 - Mail Carrier
				22 - Public Utility
				23 - Rental Truck over 10,000 lbs.
				24 - Truck Operating with Crash Attenuator Equipment
				99 - Reported as Unknown
Emergency Motor Vehicle Use			Vehicle Related Factors
0 - Not Applicable
2 - Non-Emergency, Non-Transport
3 - Non-Emergency Transport
4 - Emergency Operation, Emergency Warning Equipment Not in Use
5 - Emergency Operation, Emergency Warning Equipment in Use
6 - Emergency Operation, Emergency Warning Equipment in Use Unknown
8 - Not Reported
9 - Reported as Unknown
Fire Occurrence
0 - No or Not Reported
1 - Yes

TRAILER INFORMATION FOR VEHICLE# 1

Trailer VIN (1)				vPIC Make vPIC Body Class vPIC Trailer Body Type vPIC Model vPIC Model Year
00000000000000000 - No VIN Required, Not a Vehicle for Road Use
77777777777777777 - No Trailing Units
88888888888888888 - Not Reported
99999999999999999 - Reported as Unknown
Trailer GVWR

Trailer VIN (2)				vPIC Make vPIC Body Class vPIC Body Type vPIC Model vPIC Year
00000000000000000 - No VIN Required, Not a Vehicle for Road Use
77777777777777777 - No Trailing Units
88888888888888888 - Not Reported
99999999999999999 - Reported as Unknown
Trailer GVWR

Trailer VIN (3)				vPIC Make vPIC Body Class vPIC Trailer Body Type vPIC Model vPIC Year
00000000000000000 - No VIN Required, Not a Vehicle for Road Use
77777777777777777 - No Trailing Units
88888888888888888 - Not Reported
99999999999999999 - Reported as Unknown
Trailer GVWR

2021 Fatality Analysis Reporting System PRECRASH LEVEL (VEHICLE/DRIVER) FOR VEHICLE# 1

State Number Consecutive Number **Vehicle Number

Contributing Circumstances, Motor Vehicle				Trafficway Description
00 - None Noted				0 - Non-Trafficway or Driveway Access
				1 - Two-Way, Not Divided
01 - Tires
				2 - Two-Way, Divided, Unprotected Median
02 - Brake System				3 - Two-Way, Divided, Positive Median Barrier
03 - Steering				4 - One-Way Trafficway
				5 - Two-Way, Not Divided With a Continuous Left-Turn Lane
04 - Suspension
				6 - Entrance/Exit Ramp
05 - Power Train				8 - Not Reported
				9 - Reported as Unknown
06 - Exhaust System
07 - Head Lights
08 - Signal Lights
09 - Other Lights
10 - Wipers
11 - Wheels
12 - Mirrors
13 - Windows/Windshield
14 - Body, Doors
15 - Truck Coupling/Trailer Hitch/Safety Chains
16 - Safety Systems
17 - Vehicle Contributing Factors - No Details
97 - Other
99 - Reported as Unknown
Total Lanes in Roadway			Speed Limit
0 - Non-Trafficway or Driveway Access
1 - One lane
2 - Two lanes
3 - Three lanes
4 - Four lanes
5 - Five lanes
6 - Six lanes
7 - Seven or more lanes
8 - Not Reported
9 - Reported as Unknown

Roadway Alignment				Roadway Grade
0 - Non-Trafficway or Driveway Access				0 - Non-Trafficway or Driveway Access
1 - Straight				1 - Level
2 - Curve Right				2 - Grade, Unknown Slope
3 - Curve Left				3 - Hillcrest
4 - Curve - Unknown Direction				4 - Sag (Bottom)
8 - Not Reported				5 - Uphill
9 - Reported as Unknown				6 - Downhill
				8 - Not Reported
				9 - Reported as Unknown
Roadway Surface Type				Roadway Surface Conditions
0 - Non-Trafficway or Driveway Access				00 - Non-Trafficway or Driveway Access
1 - Concrete				01 - Dry
2 - Blacktop, Bituminous, or Asphalt				02 - Wet
3 - Brick or Block				03 - Snow
4 - Slag, Gravel or Stone				04 - Ice/Frost
5 - Dirt				05 - Sand
7 - Other				06 - Water (Standing or Moving)
8 - Not Reported				07 - Oil
9 - Reported as Unknown				08 - Other
				10 - Slush
				11 - Mud, Dirt or Gravel
				98 - Not Reported
				99 - Reported as Unknown
Traffic Control Device				Device Functioning
00 - No Controls				0 - No Controls
01 - Traffic control signal (on colors) without Pedestrian Signal				1 - Device Not Functioning
02 - Traffic control signal (on colors) with Pedestrian Signal				2 - Device Functioning-Functioning Improperly
03 - Traffic control signal(on colors) not known whether or not Pedestrian Signal				3 - Device Functioning Properly
				4 - Device Not Functioning or Device Functioning Improperly, Specifics Unknown
04 - Flashing Traffic Control Signal
07 - Lane Use Control Signal				8 - Not Reported
08 - Other Highway Traffic Signal				9 - Reported as Unknown
09 - Unknown Highway Traffic Signal
20 - Stop Sign
21 - Yield Sign
23 - School Zone Sign/Device
28 - Other Regulatory Sign
29 - Unknown Regulatory Sign
40 - Warning Sign
50 - Person
65 - Railway Crossing Device
97 - Not Reported
98 - Other
99 - Reported as Unknown

Driver's Vision Obscured By	Driver Maneuvered to Avoid
Driver Distracted By	Pre-Event Movement(Prior to Recognition of Critical Event)

Critical Event-Precrash (Category)			Critical Event -Precrash (Event)
1 - This Vehicle Loss of Control Due To:
2 - This Vehicle Traveling
3 - Other Motor Vehicle in Lane
4 - Other Motor Vehicle Encroaching into Lane
5 - Pedestrian or Pedalcyclist or Other Non-Motorist
6 - Object or Animal
7 - Other
9 - Unknown
Attempted Avoidance Maneuver				Pre-Impact Stability
00 - No Driver Present / Unknown if Driver Present				0 - No Driver Present / Unknown if Driver Present
01 - No Avoidance Maneuver				1 - Tracking
05 - Releasing brakes				2 - Skidding longitudinally rotation less than 30 degrees
06 - Steering left				3 - Skidding laterally clockwise rotation
07 - Steering right				4 - Skidding laterally counterclockwise rotation
08 - Braking and steering left				5 - Skidding Laterally, Rotation Direction Unknown
09 - Braking and steering right				7 - Other vehicle loss-of-control (specify:)
10 - Accelerating				9 - Precrash stability unknown
11 - Accelerating and steering left
12 - Accelerating and steering right
15 - Braking and Unknown Steering Direction
16 - Braking
98 - Other actions (specify:)
99 - Unknown/Not Reported
Pre-Impact Location			Crash Type
0 - No Driver Present / Unknown if Driver Present
1 - Stayed in original travel lane
2 - Stayed on roadway, but left original travel lane
3 - Stayed on roadway, not known if left original travel lane
4 - Departed roadway
5 - Remained off roadway
6 - Returned to roadway
7 - Entered roadway
9 - Unknown

2021 Fatality Analysis Reporting System DRIVER LEVEL FOR VEHICLE# 1

State Number Consecutive Number **Vehicle Number

Driver Presence			Drivers License State
0 - No Driver Present/Not Applicable
1 - Yes
9 - Unknown
Driver Zip Code			Violations Charged
00000 - Not resident of U.S. or Territories
99998 - Not Reported
99999 - Reported as Unknown
Speeding Related				Condition (Impairment) At Time of Crash
0 - No
				00 - None/Apparently Normal
2 - Yes, Racing
3 - Yes, Exceeded Speed Limit				01 - Ill, Blackout
4 - Yes, Too Fast for Conditions				02 - Asleep or Fatigued
5 - Yes, Specifics Unknown
				03 - Walking with a Cane or Crutches, etc.
9 - Reported as Unknown
				04 - Paraplegic or in a Wheelchair
				05 - Impaired Due to Previous Injury
				06 - Deaf/Hard of Hearing
				07 - Blind/Low Vision
				08 - Emotional (depressed, angry, disturbed, etc.)
				09 - Under the Influence of Alcohol, Drugs or Medication
				10 - Physical Impairment - No Details
				96 - Other Physical Impairment
				98 - Not Reported
				99 - Reported as Unknown if Impaired
Driver Related Factors

DRIVER LICENSE FOR VEHICLE# 1

Non-CDL License Type				Non-CDL License Status
0 - Not Licensed				0 - Not licensed
1 - Full Driver License				1 - Suspended
2 - Intermediate Driver License				2 - Revoked
7 - Learner's Permit				3 - Expired
8 - Temporary License				4 - Canceled or denied
9 - Unknown License Type				6 - Valid
				9 - Unknown License Status

Commercial Motor Vehicle License Status				Compliance With CDL Endorsements
00 - No (CDL)				0 - No Endorsements required for this vehicle
01 - Suspended				1 - Endorsement(s) Required, Complied with
02 - Revoked				2 - Endorsement(s) Required, Not Complied with
03 - Expired				3 - Endorsement(s) Required, Compliance Unknown
04 - Cancelled or Denied				9 - Unknown, if required
05 - Disqualified
06 - Valid
07 - Commercial Learner’s Permit (CLP)
08 - Other Not-Valid
99 - Unknown License Status
License Compliance with Class of Vehicle				Compliance with license Restrictions
0 - Not licensed				0 - No Restrictions or Not Applicable
1 - No license required for this class vehicle				1 - Restrictions Complied With
2 - No valid license for this class vehicle				2 - Restrictions Not Complied With
3 - Valid license for this class vehicle				3 - Restrictions, Compliance Unknown
8 - Unknown If CDL and/or CDL endorsement required for this vehicle				9 - Unknown
9 - Unknown
Driver Height(Feet)			Driver Height(Inches)
Driver Weight

DRIVER COUNTERS FOR VEHICLE# 1

Previous Rec. Crashes	Previous Rec. Susp.,Revoc. and Withdrawals Previous Underage Admin. Per Se for BAC Previous Admin. Per Se for BAC (Not Underage) Previous Recorded Other Susp/Revoc/Withdrawals
Previous DWI Convictions	Previous Recorded Speeding Convictions
Previous Other Moving Violation Convictions	Date of Oldest Crash, Suspension, Convictions /
Date of Most Recent Crash, Susp., Convictions /

2021 Fatality Analysis Reporting System

PERSON LEVEL (MV OCCUPANT) FOR VEHICLE# 1 AND PERSON# 1

State Number Consecutive Number **Vehicle Number **Person Number

Age				Sex
				1 - Male
				2 - Female
				8 - Not Reported
				9 - Reported as Unknown
Person Type				Injury Severity
01 - Driver of a Motor Vehicle In-Transport				0 - No Apparent Injury (O)
02 - Passenger of a Motor Vehicle In-Transport				1 - Possible Injury (C)
03 - Occupant of a Motor Vehicle Not In- Transport				2 - Suspected Minor Injury (B)
09 - Unknown Occupant Type in a Motor Vehicle In- Transport				3 - Suspected Serious Injury (A)
				4 - Fatal Injury (K)
				5 - Injured, Severity Unknown
				6 - Died Prior to Crash*
				9 - Unknown/Not Reported
Seating Position				Transported to First Medical Facility By
11 - Front Seat, Left Side				0 - Not Transported for Treatment
12 - Front Seat, Middle				1 - EMS Air
13 - Front Seat, Right Side				2 - Law Enforcement
18 - Front Seat, Other				3 - EMS Unknown Mode
19 - Front Seat, Unknown				4 - Transported Unknown Source
21 - Second Seat, Left Side				5 - EMS Ground
22 - Second Seat, Middle				6 - Other
23 - Second Seat, Right Side				8 - Not Reported
28 - Second Seat, Other				9 - Reported as Unknown
29 - Second Seat, Unknown
31 - Third Seat, Left Side
32 - Third Seat, Middle
33 - Third Seat, Right Side
38 - Third Seat, Other
39 - Third Seat, Unknown
41 - Fourth Seat, Left Side
42 - Fourth Seat, Middle
43 - Fourth Seat, Right Side
48 - Fourth Seat, Other
49 - Fourth Seat, Unknown
50 - Sleeper Section of Cab (Truck)
51 - Other Passenger in enclosed passenger or cargo area
52 - Other Passenger in unenclosed passenger or cargo area
53 - Other Passenger in passenger or cargo area, unknown whether or not enclosed
54 - Trailing Unit
55 - Riding on Exterior of Vehicle
56 - Appended to a Motor Vehicle for Motion
98 - Not Reported
99 - Reported as Unknown

SAFETY DEVICES FOR VEHICLE# 1 AND PERSON# 1

Restraint System Use Type of Restraint System in Use				Helmet Use Helmet Use
01 - Shoulder Belt Only Used				05 - DOT-Compliant Motorcycle Helmet
02 - Lap Belt Only Used				16 - Helmet, Other than DOT-Compliant Motorcycle Helmet
03 - Shoulder and Lap Belt Used				17 - No Helmet
04 - Child Restraint Type Unknown				19 - Helmet, Unknown if DOT-Compliant
06 - Racing-Style Harness Used				20 - Not Applicable
08 - Restraint Used - Type Unknown				98 - Not Reported
10 - Child Restraint System - Forward Facing				99 - Reported as Unknown if Helmet Worn
11 - Child Restraint System - Rear Facing				Indication of Helmet Misuse?
12 - Booster Seat
20 - None Used/Not Applicable
97 - Other				0 - No Indication of Misuse
98 - Not Reported				1 - Yes, Indication of Misuse
99 - Reported as Unknown				7 - None Used/Not Applicable
Indication of Restraint System Misuse?
0 - No Indication of Misuse
1 - Yes, Indication of Misuse
7 - None Used/Not Applicable
Air Bag Deployed				Ejection
				0 - Not Ejected
01 - Deployed- Front
				1 - Totally Ejected
02 - Deployed- Side (door, seatback)
				2 - Partially Ejected
03 - Deployed- Curtain (roof)
				3 - Ejected - Unknown Degree
07 - Deployed- Other (Knee, air belt, etc.)
				7 - Not Reported
08 - Deployed- Combination
				8 - Not Applicable
09 - Deployment- Unknown Location
				9 - Reported as Unknown if Ejected
20 - Not Deployed
98 - Not Reported
99 - Reported as Deployment Unknown
Ejection Path				Extrication
0 - Ejection Path Not Applicable				0 - Not Extricated or Not Applicable
1 - Through Side Door Opening				1 - Extricated
2 - Through Side Window				9 - Unknown
3 - Through Windshield
4 - Through Back Window
5 - Through Back Door/Tailgate Opening
6 - Through Roof Opening (sun-roof, convertible top down)
7 - Through roof (convertible top up)
8 - Other Path (e.g., back of pick-up truck)
9 - Ejection Path Unknown

2021 Fatality Analysis Reporting System ALCOHOL FOR VEHICLE# 1 AND PERSON# 1

Police-Reported Alcohol Involvement				Alcohol Test Status
0 - No (Alcohol Not Involved)				0 - Test Not Given
1 - Yes (Alcohol Involved)				2 - Test Given
8 - Not Reported				8 - Not Reported
9 - Reported as Unknown				9 - Reported as Unknown if Tested
Alcohol Test Type			Alcohol Test Result
00 - Test Not Given
01 - Blood
02 - Breath Test (AC)
03 - Urine
04 - Vitreous
05 - Blood Plasma/Serum
06 - Blood Clot
07 - Liver
08 - Other Test Type
10 - Preliminary Breath Test (PBT)
11 - Breath Test, Unknown Type
95 - Not Reported
98 - Unknown Test Type
99 - Reported as Unknown if Tested

DRUG FOR VEHICLE# 1 AND PERSON# 1

Police Reported Drug Involvement				Method of Drug Determination by Police
0 - No (Drugs Not Involved)				1 - Evidential Test (Blood, Urine)
1 - Yes (Drugs Involved)				2 - Drug Recognition Expert (or Evaluator) (DRE)
8 - Not Reported				3 - Observed Behavior or SFST
9 - Reported as Unknown				7 - Other
				8 - Not Reported
Drug Test Status
0 - Test Not Given
2 - Test Given
8 - Not Reported
9 - Reported as Unknown if Tested

2021 Fatality Analysis Reporting System RACE FOR VEHICLE# 1 AND PERSON# 1

Race				Hispanic Origin
00 - Not a Fatality (not applicable)				00 - Not A Fatality (not Applicable)
01 - White				01 - Mexican
02 - Black or African American				02 - Puerto Rican
03 - North American Indian or Alaska Native				03 - Cuban
04 - Chinese				04 - Central or South American
05 - Japanese				05 - European Spanish
06 - Native Hawaiian				06 - Hispanic, Origin Not Specified or Other Origin
07 - Filipino				07 - Non-Hispanic
18 - Asian Indian				99 - Unknown
19 - Other Indian (includes South and Central America, any others, except North American or Asian Indians)
28 - Korean
38 - Samoan
48 - Vietnamese
58 - Guamanian or Chamorro
68 - Other Asian or Pacific Islander
78 - Asian or Pacific Islander, No Specific (individual) Race
97 - Multiple Races Unspecified
98 - Other Race
99 - Unknown

SUPPLEMENTAL FOR VEHICLE# 1 AND PERSON# 1

Died at Scene/En Route			Death Date / /
0 - Not Applicable
7 - Died at Scene
8 - Died En Route
9 - Unknown
Death Time :			Death Certificate Number
Fatal Injury At Work

2021 Fatality Analysis Reporting System

PERSON LEVEL (MV OCCUPANT) FOR VEHICLE# 1 AND PERSON# 2

State Number Consecutive Number **Vehicle Number **Person Number

Age				Sex
				1 - Male
				2 - Female
				8 - Not Reported
				9 - Reported as Unknown
Person Type				Injury Severity
01 - Driver of a Motor Vehicle In-Transport				0 - No Apparent Injury (O)
02 - Passenger of a Motor Vehicle In-Transport				1 - Possible Injury (C)
03 - Occupant of a Motor Vehicle Not In- Transport				2 - Suspected Minor Injury (B)
09 - Unknown Occupant Type in a Motor Vehicle In- Transport				3 - Suspected Serious Injury (A)
				4 - Fatal Injury (K)
				5 - Injured, Severity Unknown
				6 - Died Prior to Crash*
				9 - Unknown/Not Reported
Seating Position				Transported to First Medical Facility By
11 - Front Seat, Left Side				0 - Not Transported for Treatment
12 - Front Seat, Middle				1 - EMS Air
13 - Front Seat, Right Side				2 - Law Enforcement
18 - Front Seat, Other				3 - EMS Unknown Mode
19 - Front Seat, Unknown				4 - Transported Unknown Source
21 - Second Seat, Left Side				5 - EMS Ground
22 - Second Seat, Middle				6 - Other
23 - Second Seat, Right Side				8 - Not Reported
28 - Second Seat, Other				9 - Reported as Unknown
29 - Second Seat, Unknown
31 - Third Seat, Left Side
32 - Third Seat, Middle
33 - Third Seat, Right Side
38 - Third Seat, Other
39 - Third Seat, Unknown
41 - Fourth Seat, Left Side
42 - Fourth Seat, Middle
43 - Fourth Seat, Right Side
48 - Fourth Seat, Other
49 - Fourth Seat, Unknown
50 - Sleeper Section of Cab (Truck)
51 - Other Passenger in enclosed passenger or cargo area
52 - Other Passenger in unenclosed passenger or cargo area
53 - Other Passenger in passenger or cargo area, unknown whether or not enclosed
54 - Trailing Unit
55 - Riding on Exterior of Vehicle
56 - Appended to a Motor Vehicle for Motion
98 - Not Reported
99 - Reported as Unknown

SAFETY DEVICES FOR VEHICLE# 1 AND PERSON# 2

Restraint System Use Type of Restraint System in Use				Helmet Use Helmet Use
01 - Shoulder Belt Only Used				05 - DOT-Compliant Motorcycle Helmet
02 - Lap Belt Only Used				16 - Helmet, Other than DOT-Compliant Motorcycle Helmet
03 - Shoulder and Lap Belt Used				17 - No Helmet
04 - Child Restraint Type Unknown				19 - Helmet, Unknown if DOT-Compliant
06 - Racing-Style Harness Used				20 - Not Applicable
08 - Restraint Used - Type Unknown				98 - Not Reported
10 - Child Restraint System - Forward Facing				99 - Reported as Unknown if Helmet Worn
11 - Child Restraint System - Rear Facing				Indication of Helmet Misuse?
12 - Booster Seat
20 - None Used/Not Applicable
97 - Other				0 - No Indication of Misuse
98 - Not Reported				1 - Yes, Indication of Misuse
99 - Reported as Unknown				7 - None Used/Not Applicable
Indication of Restraint System Misuse?
0 - No Indication of Misuse
1 - Yes, Indication of Misuse
7 - None Used/Not Applicable
Air Bag Deployed				Ejection
				0 - Not Ejected
01 - Deployed- Front
				1 - Totally Ejected
02 - Deployed- Side (door, seatback)
				2 - Partially Ejected
03 - Deployed- Curtain (roof)
				3 - Ejected - Unknown Degree
07 - Deployed- Other (Knee, air belt, etc.)
				7 - Not Reported
08 - Deployed- Combination
				8 - Not Applicable
09 - Deployment- Unknown Location
				9 - Reported as Unknown if Ejected
20 - Not Deployed
98 - Not Reported
99 - Reported as Deployment Unknown
Ejection Path				Extrication
0 - Ejection Path Not Applicable				0 - Not Extricated or Not Applicable
1 - Through Side Door Opening				1 - Extricated
2 - Through Side Window				9 - Unknown
3 - Through Windshield
4 - Through Back Window
5 - Through Back Door/Tailgate Opening
6 - Through Roof Opening (sun-roof, convertible top down)
7 - Through roof (convertible top up)
8 - Other Path (e.g., back of pick-up truck)
9 - Ejection Path Unknown

2021 Fatality Analysis Reporting System ALCOHOL FOR VEHICLE# 1 AND PERSON# 2

Police-Reported Alcohol Involvement				Alcohol Test Status
0 - No (Alcohol Not Involved)				0 - Test Not Given
1 - Yes (Alcohol Involved)				2 - Test Given
8 - Not Reported				8 - Not Reported
9 - Reported as Unknown				9 - Reported as Unknown if Tested
Alcohol Test Type			Alcohol Test Result
00 - Test Not Given
01 - Blood
02 - Breath Test (AC)
03 - Urine
04 - Vitreous
05 - Blood Plasma/Serum
06 - Blood Clot
07 - Liver
08 - Other Test Type
10 - Preliminary Breath Test (PBT)
11 - Breath Test, Unknown Type
95 - Not Reported
98 - Unknown Test Type
99 - Reported as Unknown if Tested

DRUG FOR VEHICLE# 1 AND PERSON# 2

Police Reported Drug Involvement				Method of Drug Determination by Police
0 - No (Drugs Not Involved)				1 - Evidential Test (Blood, Urine)
1 - Yes (Drugs Involved)				2 - Drug Recognition Expert (or Evaluator) (DRE)
8 - Not Reported				3 - Observed Behavior or SFST
9 - Reported as Unknown				7 - Other
				8 - Not Reported
Drug Test Status
0 - Test Not Given
2 - Test Given
8 - Not Reported
9 - Reported as Unknown if Tested

2021 Fatality Analysis Reporting System RACE FOR VEHICLE# 1 AND PERSON# 2

Race				Hispanic Origin
00 - Not a Fatality (not applicable)				00 - Not A Fatality (not Applicable)
01 - White				01 - Mexican
02 - Black or African American				02 - Puerto Rican
03 - North American Indian or Alaska Native				03 - Cuban
04 - Chinese				04 - Central or South American
05 - Japanese				05 - European Spanish
06 - Native Hawaiian				06 - Hispanic, Origin Not Specified or Other Origin
07 - Filipino				07 - Non-Hispanic
18 - Asian Indian				99 - Unknown
19 - Other Indian (includes South and Central America, any others, except North American or Asian Indians)
28 - Korean
38 - Samoan
48 - Vietnamese
58 - Guamanian or Chamorro
68 - Other Asian or Pacific Islander
78 - Asian or Pacific Islander, No Specific (individual) Race
97 - Multiple Races Unspecified
98 - Other Race
99 - Unknown

SUPPLEMENTAL FOR VEHICLE# 1 AND PERSON# 2

Died at Scene/En Route			Death Date / /
0 - Not Applicable
7 - Died at Scene
8 - Died En Route
9 - Unknown
Death Time :			Death Certificate Number
Fatal Injury At Work

NHTSA Form 1667