Form 1771 CIREN Pedestrian Interview Form

CIREN Pedestrian Interview Form – (Pedestrian)

Case Number:				CIREN ID:
Interview date				Other ID
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 (skip if unknown to pedestrian)
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

3. Pedestrian Description of Crash Event(s)
(free text)	(diagram)
3.1 Additional questions to ask interviewee based on other data sources (vehicle inspection, medical records, etc.)

4. Pedestrian clothing
4.1 What kind of shoes were you wearing? Color________________	□ 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? Color________________	□ Long pants □ Shorts □ Dress □ Long skirt □ Short skirt □ Not sure
4.3 What kind of top were you wearing? Color________________	□ Shirt/blouse (includes dress) □ Sweater/sweatshirt (includes hoodie) □ Not sure
4.4 What kind of outerwear were you wearing? Color________________	□ 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
4.7 Did you take any actions to increase your visibility to traffic?	□ No □ Reflective clothing □ Lights □ Other, specify__________________
4.8 Was an object carried or worn? (e.g., suitcase or backpack)	□ No □ Yes, specify ____________________

5. Pedestrian anthropometry
5.1 Standing knee height [cm]	5.2 Standing hip height [cm]	5.3 Standing shoulder height [cm]
□ _______________ □ Unable to acquire	□ _______________ □ Unable to acquire	□ _______________ □ Unable to acquire

6. Pre-impact striking vehicle information
6.1 From which direction did the striking vehicle approach you? (relative to pedestrian’s stance)	□ Front □ Left □ Right □ Back □ Unknown
6.2 Were there other vehicles approaching you? If so, from which direction?	□ No □ Yes, same direction as striking vehicle □ Yes, opposite direction as striking vehicle □ Yes, perpendicular to striking vehicle □ Unknown
6.3 Did you hear the vehicle approaching?	□ Yes □ No □ Unknown
6.4 Did you see the vehicle that struck you before the impact? If “No” or “Unknown” skip to question 6.5.	□ Yes □ No □ Unknown
6.4a Did the driver lose control of the vehicle before impact?	□ Yes □ No □ Unknown
6.4b Did the driver take any avoidance actions prior to the collision?	□ Braking with lock-up □ Braking without lock-up □ Releasing brakes □ Accelerating □ Steering left □ Steering right □ Other, specify _________________________ □ None □ Unknown
6.4c Did the vehicle skid or rotate?	□ No □ Sideways skid □ Clockwise rotation (front end to the right) □ Counterclockwise rotation (front end to the left) □ Unknown
6.4d Did you see the driver of the vehicle? If “No” or “Unknown” skip to question 6.4e	□ Yes □ No □ Unknown
6.4d1. Did the driver of the vehicle make eye contact with you?	□ Yes □ No □ Unknown
6.4d2 Before the collision, was the driver attentive to the driving task or obviously distracted by something?	□ Not distracted (attentive) □ Distracted by another person in vehicle □ Distracted by handheld electronic device □ Distracted, source outside of vehicle □ Distracted, unknown source □ Sleeping □ Other, specify ________________________ □ Unknown
6.4e Did the driver provide any communication before impact? Select all that apply.	□ Auditory communication □ Physical Gesture □ Other, specify___________________________ □ None □ Unknown
6.4f Did you try to communicate with the driver before impact? Select all that apply.	□ Auditory communication □ Physical gesture □ Other, specify___________________________ □ None □ Unknown
6.5 Did you think the driver of the vehicle saw you before impact?	□ Yes □ No □ Unknown

7. Pre-impact pedestrian information
7.1 Were you pulling anything?	□ No □ Pushing a cart, stroller, bicycle, other □ Pulling a wagon, luggage, other □ Other, specify __
7.2 Were you pushing anything?	□ No □ Pushing a cart, stroller, bicycle, other □ Pulling a wagon, luggage, other □ Other, specify ________________________
7.3 Were you moving (walking/jogging) alone, with someone else, or in a group?	□ Alone □ One other person □ Two other people □ Three or more other people □ Unknown
7.4 Were any other pedestrians struck by the vehicle?	□ No □ Yes, specify how many ____ □ Unknown
7.5 Do you remember what you were doing just prior to impact? If “No” skip to question 7.6	□ No □ Yes
7.5a Just prior to the impact, were you: (attitude)	□ Standing, walking, or running □ Crouching □ Kneeling □ Bending at waist □ Other, specify ________________________ □ Unknown
7.5b Just prior to the impact, were you: (motion)	□ Stopped □ Walking □ Walking rapidly □ Running or jogging □ Jumping □ Falling or rising □ Other, specify ________________________ □ Unknown
7.5c If you were in motion, were you moving at your usual pace?	□ Yes □ Slower □ Faster □ Unknown
7.5d Just prior to the impact, were you: (road crossing)	□ Crossing road straight □ Crossing road diagonally □ Moving in road with traffic □ Moving in road against traffic □ Off road approaching road □ Off road going away from road □ Off road crossing driveway □ Off road moving along driveway □ Other, specify ________________________ □ Unknown
7.5e Relative to the vehicle, what direction was your motion?	□ Stopped □ Toward vehicle □ Away from vehicle □ Left-to-right in front of vehicle □ Right-to-left in front of vehicle □ Other, specify ________________________ □ Unknown
7.5f Before trying to avoid being struck by the vehicle, was your chest/trunk:	□ Facing vehicle □ Facing away from vehicle □ Left side to vehicle □ Right side to vehicle □ Other, specify ________________________ □ Unknown
7.5g Where were you looking just before the impact?	□ At vehicle □ Away from vehicle □ At intended path □ At another vehicle or object □ Other, specify ________________________ □ Unknown
7.5h Did anything obstruct your view of the approaching vehicle? Select all that apply.	□ No □ Other moving vehicle □ Parked (or stationary) vehicle □ Tree/shrubbery/foliage □ Permanent object □ Glare □ Other, specify ________________________
7.5i Were you using a cell phone at the time of the crash? Select all that apply.	□ No □ Talking on the phone □ Reading/answering a text message □ Streaming a video □ Viewing the screen □ Wearing ear buds or head phones to listen to music/podcast
Pedestrian avoidance attempt
7.6 Do you remember any specifics about the moment the vehicle struck you? If “No” skip questions 7.6a through 7.6i.	□ No □ Yes
7.6a Did you do anything to avoid being hit, like: Select all that apply. If “No” or “Unknown” skip to question 7.6d	□ No □ Stopping □ Accelerating pace without changing direction □ Accelerating pace while changing direction □ Jumping □ Turning toward vehicle □ Turning away from vehicle □ Diving or falling down □ Other, specify ________________________ □ Unknown (can’t remember)
7.6b If so, which direction did you move?	□ Toward vehicle □ Away from vehicle □ Left-to-right in front of vehicle □ Right-to-left in front of vehicle □ Other, specify ________________________ □ Unknown (can’t remember)
7.6c Did you use your hands to: Select all that apply.	□ Vault corner of vehicle □ Vault on to vehicle □ Brace against vehicle □ Crouch and brace hands against vehicle □ Unknown
Positioning at time of crash
7.6d What portion of the vehicle first struck you?	□ Front □ Corner □ Side □ Unknown
7.6e Where were you when you were struck?	□ Stepping off the curb □ On the shoulder □ In the crosswalk area □ In the road □ On the sidewalk □ Other, specify __________________ □ Unknown
7.6f When struck by the vehicle, was your chest:	□ Facing vehicle □ Facing away □ Left side to vehicle □ Right side to vehicle □ Other, specify________________ □ Unknown
7.6g Which way was your head facing, relative to your chest, at impact?	□ To front □ To left □ To right □ Up □ Down □ Other, specify _______________ □ Unknown
7.6g1 Where were your arms impact?	□ At sides □ Folded across chest □ Hands clasped behind back □ Hands on hips □ Hands in pockets □ Pushing/Pulling □ Raising to protect head □ Unknown
7.6g2 One or both arms: (specify)	□ Extended upward □ Extended to side □ Extended forward bracing □ Extended holding object □ Extended holding on shoulder or head □ Other, specify ______________________ □ Unknown
7.6h Where were your legs at Impact? (specify)	□ Together □ Apart laterally □ Apart right leg forward □ Apart left leg forward □ Apart forward leg unknown □ Left foot off ground □ Right foot off ground □ Both feet off ground □ Other, specify_________________________ □ Unknown
7.6i Can you describe your body’s movement after being hit by the vehicle? (text field)	(free text)

8. Pedestrian condition
8.1 Before the crash, how were you feeling?	□ Normal □ Other, specify ____________________
8.2 Do you think your mental status was clear leading up to the crash?	□ Yes □ No, specify _______________________
8.3 Did you feel that you were in a rush?	□ Yes □ No
8.4 Would you say you are well rested or a little tired at the time of the crash?	□ Very tired □ Somewhat tired □ Well rested
8.5 Did you feel impaired by any substance? Select all that apply.	□ No □ Alcohol □ Prescription Drugs □ Other, specify _____________________
8.6 Were you traveling alone? If “No” skip to question 8.7	□ Yes □ No
8.6a Were you talking to someone else immediately before the impact?	□ Yes □ No
8.6b Were you looking at someone else in your group immediately before the impact?	□ Yes □ No
8.7 Do you need glasses/contacts to see far away? Were you wearing them?	□ Yes, wearing them □ Yes, not wearing them □ No □ N/A
8.8 Were you wearing sunglasses or otherwise shielding your eyes from glare?	□ Yes □ No
8.9 Were you looking down to shield your face from the rain, snow or wind?	□ Yes □ No
8.10 If the crash occurred during precipitation: Were you using an umbrella?	□ Yes □ No

9. Environment
9.1 When the crash occurs during Twilight or night in the presence of street lighting: Do you remember whether you crossed:	□ In front of the area lit by the street light □ In the area lit by the street light □ Behind the area lite by the street light
9.1a When the crash occurs during Twilight or night: Did you see whether the vehicle that stuck you had its headlights on?	□ Yes □ No
9.1b When the crash occurs during Twilight or night: Did you see the headlights before or after you entered the road?	□ Before □ After
9.2 Was there a pedestrian signal where you crossed the road? If “No” or “Unknown” skip 9.2a through 9.2d	□ Yes □ No
9.2a Do you have to push a button to make the pedestrian signal work?	□ Yes □ No
9.2b Did you activate the pedestrian signal?	□ Yes □ No
9.2c Do you remember what the pedestrian signal status was when you entered the road?	□ Indicating walk □ counting down □ flashing stop □ stop
9.2d If the crossing has a pedestrian signal: Do you feel the signal is long enough to let people cross the road?	□ Yes □ No

10. Trip Details
10.1 Are you familiar with the area where the crash occurred?	□ Yes □ No
10.2 Why were you walking when the crash occurred?	□ No car □ No license □ Faster to walk than drive □ Car not running □ Exercise □ Other, Specify __________________
10.3 Where were you coming from at the time of the crash?	□ Home □ Work/School □ Stores □ Entertainment
10.4 What was your destination?	□ Home □ Work/School □ Stores □ Entertainment
10.5 What was the purpose of the trip in which the crash occurred?	□ Work □ Leisure □ Exercise □ Other, Specify _______________
10.6 Why did you choose the route you were taking?	□ Most convenient □ Fastest □ Nice scenery □ Increased length for physical activity
10.7 Is this the shortest route to your destination?	□ Yes □ No □ Unknown
10.7a How often do you walk this route?	□ Less than once a month □ Once a month □ Twice a month □ Every week □ More than once a week □ Every day
10.7b Are you familiar with this route? If “No” skip question 10.7c	□ Yes □ No
10.7c What time of day do you usually walk this route?	□ Around sunrise □ Morning □ Afternoon □ Late afternoon □ Around sunset □ Night
10.8 Did you feel safe walking in this area before you were hit?	□ Completely Safe □ Concerned about traffic □ Concerned about other risk □ Not safe at all
10.8a What factors influenced this?	(free text)
10.9 Did anything along this route surprise you the day of the crash?	□ Placement of signs □ Timing of signals □ Pavement markings □ Volume of traffic □ Other, Specify __________________________

11. Behavior
11.1 How often do you walk in general?	□ Less than once a month □ Once a month □ Twice a month □ Every week □ More than once a week □ Every day
11.2 When you walk, where do you go most often?	□ Work/School □ Stores □ Entertainment
11.3 Do you always walk on sidewalk?	□ Yes □ No Explain: ______________________
11.4 Do you always cross at crosswalk?	□ Yes □ No Explain: ______________________
11.5 Do you always wait for a walk signal when its available?	□ Yes □ No Explain: ______________________
11.6 Which of the following modes of transportation do you use?	□ Car □ Bike □ Scooter/Other Micro Mobility □ Bus □ Train □ Walk □ Other, Specify ____________________