Form 1770 CIREN Occupant Interview Form

CIREN Occupant Interview Form

Case Number:				CIREN ID:
Interview date				Other ID
CIREN case subject role:	□ Driver (also complete driver-specific sections 9 and 10) □ Passenger, seat location ______________________
Admission	□ Direct □ Transfer from __________________ □ Other ____________________
Natal sex	□ Male □ Female		Gender identity			□ Male □ Female □ Non-binary
Age [□ y □ m]		Weight [□ lb □ kg]						Height [□ ft in □ cm]

1. Vehicle Identification
1.1 Vehicle make (e.g., Chevrolet, Honda)	__________________________________ □ Not sure
1.2 Vehicle model (e.g, Traverse, Accord)	__________________________________ □ Not sure
1.3 Vehicle model year	__________________________________ □ Not sure
1.4 Vehicle owner	__________________________________ □ Not sure
1.5 Vehicle location	__________________________________ □ Not sure
1.6 Insurance company/agency	__________________________________ □ Not sure

2. Basic Crash Information
2.1 Date and time of crash	___/___/20____ _______□ AM □ PM □ Not sure
2.2 Crash location	□ Not sure
2.2a. Specific location (e.g., address, intersection)
2.2b. County
2.2c. State
2.3 Police department	__________________________________ □ Not sure
2.4 Did the vehicle automatically notify EMS/911? (e.g., OnStar, SYNC, Safety CONNECT)	□ Yes □ No □ Not sure

3. Description of Crash Event(s)
(free text)	(diagram)
3.1 Which part of the vehicle sustained the most damage?	□ Front □ Left side □ Right side □ Back □ Other _________________________________ □ Not sure
3.2 Did the vehicle roll over?	□ Yes □ No □ Not sure
3.3 Did the vehicle catch on fire?	□ Yes □ No □ Not sure
3.4 Where did the vehicle come to rest? (e.g., ditch, facing north)
3.5 Additional questions to ask interviewee based on other data sources (vehicle inspection, medical records, etc.)

4. Occupant clothing
4.1 What kind of shoes were you wearing?	□ Sneaker – low-top □ Sneaker – high-top □ Flat (includes men’s dress shoe) □ Medium heel (less than one inch) □ High heel (more than one inch) □ Sandal - flat □ Sandal – with lifted heel □ Boot – ankle height (below calf) □ Boot – knee height (at or above calf) □ Boot – heavy, steel toe, work boot □ Not sure
4.2 What kind of bottom clothing were you wearing? Note color, if possible.	□ Long pants □ Shorts □ Dress □ Long skirt □ Short skirt □ Not sure
4.3 What kind of top were you wearing? Note color, if possible.	□ Shirt/blouse (includes dress) □ Sweater/sweatshirt (includes hoodie) □ Not sure
4.4 What kind of outerwear were you wearing? Note color, if possible.	□ Thin coat (e.g., windbreaker) □ Thick coat (e.g., puffy coat, winter jacket) □ Not sure □ None
4.5 Were you wearing eyeglasses or sunglasses?	□ Yes (Did they □ break, or □ get knocked off?) □ No
4.6 Were you wearing any accessories?	□ Bracelet □ Earring □ Necklace □ Ring □ Watch □ Gloves/mittens □ Hat with brim □ Hat without brim □ Other _________________________________ □ Not sure □ None

5. Occupant anthropometry
5.1 Seated knee height [cm]	5.2 Buttocks to knee length [cm]	5.3 Seated height [cm]
□ _______________ □ Unable to acquire	□ _______________ □ Unable to acquire	□ _______________ □ Unable to acquire

6. Case Occupant Seating and Restraint
6.1 Which seat were you using at the time of the crash?	Front row: □ left □ middle □ right Second row: □ left □ middle □ right Third row: □ left □ middle □ right □ Other (specify): __________________
6.2 Were you wearing the seat belt at the time of the crash?	□ Yes □ No □ Not sure
6.2a If the belt was used, how was the lap portion of the belt positioned?	□ Snug and low across hips and upper thighs (below belly) □ Across belly/abdomen □ Underneath (sitting on lap belt) □ Unsure □ Other (specify) : __________________
6.2b If the belt was used, how was the shoulder belt positioned?	□ Snug and across collarbone □ Touching neck (too far inboard) □ On edge of shoulder (too far outboard) □ Under arm □ Behind back or wrapped around seat back □ Unsure □ Other (specify) : __________________
6.2c If you were wearing a heavy jacket or other thick/bulky clothing, did you have to reposition the jacket or belt?	□ Yes: __________________ □ No □ N/A
6.2d Do you recall any discomfort with the shoulder belt at the neck?	□ Yes: __________________ □ No
6.2e Do you recall any discomfort with the lap belt over your waist or abdomen?	□ Yes: __________________ □ No
6.3 Can you estimate the fore/aft seat position?	□ Very far forward □ Between front and middle □ Approximately middle □ Between middle and rear □ Very far rearward □ Not adjustable □ Unsure
6.4 Can you describe the seat recline angle?	□ Almost fully upright □ Slight recline (head still above beltline) □ Moderate recline (head approximately at beltline/lower windowsill) □ Full recline (as far back as possible) □ Not adjustable □ Unsure
6.5 Do you remember making any adjustments to the seat or seat belt before or during this trip?	□ No □ Yes (if yes, complete 6.5a-6.5c)
6.5a Seat position (fore/aft, up/down, recline)	□ No □ Yes Describe:
6.5b Headrest	□ No □ Yes Describe:
6.5c Shoulder belt D-ring	□ No □ Yes Describe:
6.5d If driver, steering wheel tilt position	□ Highest □ Middle □ Lowest □ Not sure □ Not adjustable □Not driver
6.5e If driver, steering wheel telescope position	□ Fully in (farthest forward) □ Middle □ Fully out (farthest rearward) □ Not sure □ Not adjustable □Not driver
6.6 Can you describe how your body was positioned in the moments before the crash?	(free text)
6.6a How was your pelvis/buttocks positioned?	□ Centered on the seat cushion □ Biased/twisted to the left □ Biased/twisted to the right □ Other (specify) __________________________ □ Not sure
6.6b How was your torso positioned?	□ Centered, upright with back against seatback □ Centered, leaning forward □ Leaning to the left □ Leaning to the right □ Twisting around left side to back □ Twisting around right side to back □ Other (specify) __________________________ □ Not sure
6.6c How were your legs positioned?	□ Thighs straight forward, knees bent, feet on floor □ Thighs splayed out, knees bent, feet on floor □ Legs crossed □ Sitting on leg(s) □ Feet on seat □ Feet on dash (or front seatback) □ Other (specify) __________________________ □ Not sure
6.6d How were your hands/arms positioned?	□ On steering wheel, hands at _______________ □ In lap □ Bracing against _________________________ □ Other (specify) __________________________ □ Not sure
6.7 Were you slouched?	□ No □ Yes □ Not sure
6.8 Which airbags deployed at your seating position?	□ Steering wheel or upper dashboard □ Knee □ Side seat (outboard) □ Side curtain □ Other_________________________________ □ Not sure
6.9 Did you brace prior to the crash?	□ No □ Yes (describe___________________________) □ Not sure
6.10 If the occupant was a child, was a CRS used?	□ No □ Yes □ Rear-facing □ Forward-facing □ Secured by belt □ Secured by LATCH Make/model __________________________ Current location _______________________

7. Post-Crash and Injury information
7.1 How did you get out of the vehicle?	□ Independently/by self □ With assistance from someone □ Removed by paramedics/emergency personnel □ Not sure □ Other, specify________________________
7.2 Describe the location of any injuries

8. Other occupant information
8.1 Were there other occupants in the vehicle?	□ No □ Yes, #_______ (if yes, complete 8.2 for each) □ Not sure
8.2 Other occupant details (complete to the extent possible):
8.2a Seat position	8.2b Age (yr)	8.2c Sex	8.2d Height	8.2e Weight	8.2f Belt use
□ 11 □ 12 □ 13 □ 21 □ 22 □ 23 □ 31 □ 32 □ 33 □ Other (specify): ______________		□ Male □ Female	□ ft in _____ □ cm ______	□ lb ______ □ kg ______	□ Yes □ No □ Not sure
	8.2g Transported by _________________________________ □ Not sure			8.2h Medical facility __________________________ □ Not sure
8.2a Seat position	8.2b Age (yr)	8.2c Sex	8.2d Height	8.2e Weight	8.2f Belt use
□ 11 □ 12 □ 13 □ 21 □ 22 □ 23 □ 31 □ 32 □ 33 □ Other (specify): ______________		□ Male □ Female	□ ft in _____ □ cm ______	□ lb ______ □ kg ______	□ Yes □ No □ Not sure
	8.2g Transported by _________________________________ □ Not sure			8.2h Medical facility __________________________ □ Not sure
8.2a Seat position	8.2b Age (yr)	8.2c Sex	8.2d Height	8.2e Weight	8.2f Belt use
□ 11 □ 12 □ 13 □ 21 □ 22 □ 23 □ 31 □ 32 □ 33 □ Other (specify): ______________		□ Male □ Female	□ ft in _____ □ cm ______	□ lb ______ □ kg ______	□ Yes □ No □ Not sure
	8.2g Transported by _________________________________ □ Not sure			8.2h Medical facility __________________________ □ Not sure

Complete the following sections only if the interviewee/case subject was the driver

9. Driver-specific vehicle questions
9.1 Had the vehicle been involved in any previous crashes?	□ No □ Yes: ___________________________ □ Unsure
9.1a If yes, were airbag or seatbelt components replaced?	□ No □ Yes: ___________________________ □ Unsure
9.1b If yes, was there unrepaired exterior body damage	□ No □ Yes: ___________________________ □ Unsure
9.2 Had the vehicle been subject to any safety recalls related to airbag or seatbelt components?	□ No □ Yes: ___________________________ □ Unsure
9.3 Were there any distractions just before the crash?	□ Yes (describe __________________________) □ No □ Not sure
9.4 Do you experience a medical event just before the crash? (e.g., seizure, hypoglycemia)	□ Yes (describe __________________________) □ No □ Not sure
9.5 Was there any cargo in the vehicle?	□ Yes (describe __________________________) □ No □ Not sure
9.6 Indicate whether the vehicle was equipped with the following crash avoidance systems and if they activated:	Not equipped	Not sure	Equipped	Activated, if equipped and describe observation
9.6a Lane Departure Warning	□	□	□	□
9.6b Forward Collision Warning	□	□	□	□
9.6c Blind Spot Detection/Warning	□	□	□	□
9.6d Lane Keeping Support	□	□	□	□
9.6e Crash Imminent Braking or Automatic Emergency Braking	□	□	□	□
9.6f Dynamic Brake Support	□	□	□	□
9.6g Pedestrian Automatic Emergency Braking	□	□	□	□
9.6h Rear Automatic Braking	□	□	□	□
9.6i Adaptive Cruise Control	□	□	□	□

10. Driver-specific crash questions
10.1 Which direction were you travelling?	□ North □ South □ East □ West □ Unsure, but toward_______________
10.2 Which lane were you travelling in? Lane 1 is designated as the right curb lane	□ 1 □ 2 □ 3 □ 4 □ Other, specify ____________
10.3 Did you know the crash was going to occur?	□ Yes (describe __________________________) □ No □ Not sure
10.4 Did you perform any avoidance maneuvers?	□ No □ Braking with lock up □ Braking without lock up □ Releasing brakes □ Accelerating □ Steering left □ Steering right □ Other, specify________________________ □ Not sure
10.5 Can you estimate your travel speed before the crash?	□ 1-10 mph □ 10-20 mph □ 20-30 mph □ 30-40 mph □ 40-50 mph □ 50-60 mph □ 60-70 mph □ 70+ mph □ Stopped □ Unknown
10.6 Just before the crash, what were you intending to do or were doing:	□ Going straight □ Slowing □ Turning left □ Turning right □ Stopped □ Accelerating □ Changing lanes to left □ Changing lanes to right □ Backing □ Other, specify _________________________
10.7 Did you experience any loss of control of your vehicle?	□ No □ Yes, describe__________________________
10.8 Where was your vehicle at the time of the collision?	□ Original travel lane □ Different travel lane □ In intersection □ Off roadway to left □ Off roadway to right □ Other, specify_______________________
10.9 Was your speed at the time of the collision different from your previous travel speed?	□ No □ Lower □ Higher □ Unknown
10.10 Can you estimate your travel speed at the time of the collision?	□ 1-10 mph □ 10-20 mph □ 20-30 mph □ 30-40 mph □ 40-50 mph □ 50-60 mph □ 60-70 mph □ 70+ mph □ Stopped □ Unknown
10.11 Before the crash, were you attentive to the driving task or were you distracted by: Select all that apply.	□ Talking on cell phone □ Another person in car □ Moving object in car □ Something outside the car, Specify __________ □ Sleeping or dozing □ Other, specify____________ □ Not distracted