Discussion and Assignments

Form

DATE

Crash 9 key 10/6/15

Time

0249hrs

SEVERITY

Property Damage

LOCATION

Broadway

at

1500 feet south of Union Street

CONDITIONS

C - Clear/Sunny

ROAD CONDITIONS

D - Dry

LIGHT CONDITIONS

L - Dark/Lighted

POSTED MPH

25

NUMBER OF VEHICLES

1

MANNER OF IMPACT

Other

Traffic Unit #1

Traffic Unit #2

OPERATOR #1 or PEDESTRIAN NAME (Last, First, Middle Initial)

OPERATOR #2 or PEDESTRIAN NAME (Last, First, Middle Initial)

Ski, Rochard

N/A

ADDRESS (Street Number & Name)

Proper Lic. Class

ADDRESS (Street Number & Name)

Proper Lic. Class

9 Corey Road

CITY or TOWN

STATE

ZIP CODE

SEX

CITY or TOWN

STATE

ZIP CODE

SEX

Nonantic

RI

75444

OPERATOR LICENSE #

STATE

DATE OF BIRTH Month Day Year

OPERATOR LICENSE #

STATE

DATE OF BIRTH Month Day Year

RS357887

RI

1

2

2

6

9

0

OWNER'S NAME (Enter SAME if Owner is Operator)

OWNER'S NAME (Enter SAME if Owner is Operator)

SAME

ADDRESS (Street Number and Name)

ADDRESS (Street Number and Name)

CITY or TOWN

STATE

ZIP CODE

BODY T YPE

CITY or TOWN

STATE

ZIP CODE

BODY T YPE

4 door

REGISTRATION #

STATE

VEHICLE YEAR AND MAKE

REGISTRATION #

STATE

VEHICLE YEAR AND MAKE

ACB431

RI

2009 Acura TSX color red

VEHICLE IDENTIFICATION NUMBER

VEHICLE IDENTIFICATION NUMBER

J

H

4

U

C

6

6

2

0

9

B

0

0

7

8

5

4

AUTOMOBILE INSURANCE - NAME - POLICY #

AUTOMOBILE INSURANCE - NAME - POLICY #

Rexar Insurance 55564P

PARTS OF VEHICLE DAMAGED

PARTS OF VEHICLE DAMAGED

Damage to front left wheel

VEHICLE TOWED

VEHICLE TOWED

Vehicle #

Restraint

Seat Position

Airbag

Role

NAME AND ADDRESS OF EACH INVOLVED PERSON

Date of Birth Month Day Year

Gender

Injury

Ejection

1

6 - Unknown

11 - Driver

0 - Not deployed

D - Driver

TRAFFIC UNIT #1 OPERATOR OR PEDESTRIAN #1

O - No injury

0 - Not ejected

2

TRAFFIC UNIT #2 OPERATOR OR PEDESTRIAN #2

&"-,Bold"&14&G Aspen University Traffic Crash Report

Vehicle

Non-Contact Vehicle

Pedestrian

Yes

No

M

F

Vehicle

Non-Contact Vehicle

Pedestrian

Yes

No

M

F

Yes

No

M

F

Tables

Severity		Restraint		Seating		Conditions		Manner of Impact
Fatal		0 - None		11 - Driver		C - Clear/Sunny		Front to rear
Injury		1 - Lap belt only		12 - Middle passenger		R - Rainy		Backing
Property Damage		2 - Shoulder belt only		13 - Front right passenger		S - Snow		Head on
		3 - Lap & shoulder belt		21 - Left rear passenger		I - Ice/Sleet		Angle
Posted MPH		4 - Motorcycle helmet		22 - Middle rear passenger		L - Cloudy		Other
20		5 - Child safety seat		23 - Right rear passenger
25		6 - Unknown		00 - N/A		Road Conditions
30						D - Dry
35		Ejection		Role		W - Wet/Snow
40		0 - Not ejected		D - Driver		I - Icy
45		1 - Partially ejected		O - Passenger		O - Oil
50		2 - Totally ejected		W - Witness		T - Debris
		3 - N/A		B - Bicyclist		S - Slippery
Number of Vehicles				P - Pedestrian
1		Airbag				Light Conditions
2		0 - Not deployed		Gender		D - Daylight
3		1 - Deployed		M - Male		L - Dark/Lighted
4		2 - N/A		F - Female		N - Dark/Not Lighted
5				U - Unknown		W - Dawn
		Injury				K - Dusk
Towed		K - Fatal
Yes		A - Severe injury
No		B - Minor injury
N/A		C - Suspected injury
		O - No injury