Discussion and Assignments

ASPEN UNIVERSITY CRASH REPORT FORM

DATE

Time

SEVERITY

LOCATION

at

CONDITIONS

ROAD CONDITIONS

LIGHT CONDITIONS

POSTED MPH

NUMBER OF VEHICLES

MANNER OF IMPACT

Traffic Unit #1

Traffic Unit #2

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

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

ADDRESS (Street Number & Name)

Proper Lic. Class

ADDRESS (Street Number & Name)

Proper Lic. Class

CITY or TOWN

STATE

ZIP CODE

SEX

CITY or TOWN

STATE

ZIP CODE

SEX

OPERATOR LICENSE #

STATE

DATE OF BIRTH

Month Day Year

OPERATOR LICENSE #

STATE

DATE OF BIRTH

Month Day Year

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

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

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

REGISTRATION #

STATE

VEHICLE YEAR AND MAKE

REGISTRATION #

STATE

VEHICLE YEAR AND MAKE

VEHICLE IDENTIFICATION NUMBER

VEHICLE IDENTIFICATION NUMBER

AUTOMOBILE INSURANCE - NAME - POLICY #

AUTOMOBILE INSURANCE - NAME - POLICY #

PARTS OF VEHICLE DAMAGED

PARTS OF VEHICLE DAMAGED

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

TRAFFIC UNIT #1 OPERATOR OR PEDESTRIAN #1

2

TRAFFIC UNIT #2 OPERATOR OR PEDESTRIAN #2

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

N/A

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

N/A

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