U
N
I
T
1
|
Driver's Name - Last
|
First
|
Middle
|
Suffix
|
City
|
State
|
Zip
|
Driver's Age
|
Citation Charge Code 1
|
Citation Charge 1
|
Gender
|
State
|
Class
|
Endorsements None |
Restrictions
None |
Citation Charge Code 2
|
Citation Charge 2
|
Alcohol Test Given?
|
Drug Test Given?
|
Citation Charge Code 3
|
Citation Charge 3
|
Citation Charge Code 4
|
Citation Charge 4
|
Seating Position
|
Injury Status
|
Occupant Protection
|
Airbag Deployment
|
Airbag Switch Status
|
Ejection
|
Ejection Path
|
Trapped
|
Transported to:
|
Transported by:
|
Insurance Co. Name
|
Year 1997 |
Make Chevrolet - CHEV |
Model MALIBU |
Style 4DR |
Approximate Cost to Repair or Replace 3000 |
Initial Travel Direction 4 - West |
Vehicle Action 01 - Movement essentially straight |
Speed Limit 50 |
Point of Initial Impact 02 - Right Front |
Most Damaged Area 03 - Right Side |
Extent of Damage 4 - Disabling damage |
Underride/Override 1 - None |
Total Occupants 2 |
Traffic Controls 01 - No controls present |
Vehicle Config. 01 - Passenger car |
Cargo Body Type 01 - Not applicable |
Vehicle Defect 01 - None |
Driver Condition 9 - Unknown |
Vision Obscured 01 - Not obscured |
Contributing Circumstances, Driver (up to 2)
|
| SEQUENCE OF EVENTS |
First Event 30 - Bridge/bridge rail/overpass |
Second Event
|
Third Event
|
Fourth Event
|
Most Harmful Event (by vehicle) 30 - Bridge/bridge rail/overpass |
Emergency Vehicle Type 1 - Not applicable |
Emergency Status 3 - Not Applicable |
Carrier Name
|
City
|
State
|
Zip
|
Number of Axles
|
Gross Vehicle Weight Rating
|
Placard #
|
Hazardous Materials Released?
|