01 9T REV 03-02

IF A. QUESTJON DOES NOT APPLY, ENTER A "-", IF ANSWER IS UNKNOWN ENTER '11", OTHeR EXPLAIN IN DESCRIPTION

Accident severity Type of Collision .:S-­1. No injury TYPE OF ACCIDENT -~

TRAFFIC CONTROL 2. Possible injury SEE LIST ABOVE ON 1. MV - Pedestrian R Ran Off Road - Righl "" ~ 1.00otfo:'">:n:!Cf'lml).o 3. Bruises & Abrasions

2. MV - MV L Ran Off Road -left lsi E',<llt 16BACK OF FRONT COVER 4. Broken _ or 2. F1o<Jnan 3. MV - Train A. Off1er Non-Colftsion c:

bleeding wounds ~. Tral!K: SlIF"lI 4. MV - Bicycle D. MV Animal (Do~tic) . <. Tra"" Sig-d (iomng) 5. Fataf 5. MV - Animal (Wild)s. Slop Sl9n . 172 6. MV-FixedObje<:t 2r1J&-antC:6. Ylold s;g,

7. MV - Other Ollject S. MV • Skates. s.:ooters. Skateboard 7. Ratb"oad G.2tcs: or Sigll:)1 1- ---, ---l8..-GvS<luroed6. Otlw (,.ocify) F. R•...., Melering (.cl",e) 9. No Cor<rol _ G. HOV ~ CONTRIBUTING CIRCUMSTANCES 9. Ran Off Roadway - Thru Median 3m E-IenI ~ It.. 90W ~ wZ'lll"iow Sign H. SChool Ctossmn ZOl"M:: 6. Tnrftlc LAne< ....o'qd Ift>- adNe) 00 Did NOI Contribute 21 Headlights Glaring 51 Toweo Vehicle CON;i,'!lI11Ol'1C. No PilSstnG ~ I. Scnool Ccossiog Zone 01 ~ 22 OIher Lights or Rellectors 52 Vehicle Rolling in O. Onf:..WiI'j R~d Of snoot (Ra<;'hef fNIctive Of not Pl'e-:-...ent) 902 FaiIedToY'IGidRi9htotWay Delective TratfJcLane VEHICl£ct.3.5C:E. Con:Wudiotl Q( Won: /lnJij J. P~rWl Cfossino Zone

03 Dn:Na Left of Ce1'I1er 23 Steeling Medlanism Defective 53. Dover using Cell Phone f-------------------I 04 ImlH'JP9~ 24 Tires Defective 54. Other DriYer Distractions

~ PDis~~TraffiSignc"""'.1 25 Windshield Not Clear. . . . 55. Object in Roadway VEHICLE G2.4.6 20 YO '0","" ""'.- 26 Other DetedJvo Condioon 01 Veruele 56 Aggressive DrMng ,.....-,::rL

AUGNMEm (ROADWAY CHARACTER) 07 Followed Too Closely 27 Hrt end Run . SECONDARY

1. SLmight and Level 5. Curve Grade 08 Made Illljlrope( Tum 28 DUI COO<TRIIlUTOtl

2. Grade Slraight 6. CuTve HIlIcms1 09 Had Been DrInking 29 Non-Ccllsion (Fire) VEHICLE 01.3.5 ~ 3. HilJcrest Straigh1 7. Dip Straight 10 Under The Influen<:e Of Drugs 30 Collision (Fuel c:4. Curve Level 8. DipCUflre 11 Eyasighl Deledive Uncorrected 40 Stolen

L--J -I 12 Asleep 41 Non-Conlacl Vehicle Il1\'OIved V C E

PEDESTRIAN

PEDESTRIAN

VEHIClE alA.6

VEHlCt£ 12,4 6

VEHICLEal,J.5

VEHICLE Sl,J,5

VEHlCl£Gl.3.5

VEHICLE &4.5

VEHICt£ Cl.3.5

.2. Me<ed L""""red VEHICt£ al,3,5

5. Unknown s. Refused 7. Post Mortem ll. Drug Scan

09. 8a<:~ 10. R""';;' Slopp«lln Trat11C Lane 11. RemaioParl:ed 12. CIlanging Lanes 13. Meroe ott Q:' 0.'\10 roadw

8. Signboard 9. Hllaest 10. PaI1<edVehides 11. Moving Vehicles 12. Sun or Headlighl Glare 13. C1tl>Gr

1. No Tes1

2. Blood 3. Breath 4. Other

21. Riding in Roa<tway With Traffic 22. Riding in Roadway Against T"'tfle

AlcohollDrug Test

AlcohollDrug Test Results

Drug enter. D.P. for Drug Scan Positive D.N. for Drug Scan Negative

Alcohol enter B,A.C.

s. Fanns and Fiei<ls 6. Open CounW 7. Chun:h a. Playground 9. Railroad Tmcl<s

4. Snowy 5. Icy 6. Oily

S\IRFACE CONDITIONS

1. Dry 2. Wet 3. Muddy

NUM!lEA OF VEHICl.ES INVOLYEO

1. ManufaclllringJlndusllial 2. Shopping/Busmess 3. Residential 4. School

ROADWAY FLOW

,. Divided Highway (Median Strip) 2. Divi<led HlQhway (GuamlaiO 3. Divided Highway (Olher Barrier. or Barrier Type Unlcnown) 4. Not t'\lysCaiy 0Mded 5. Clne Way T<afIic 6. lJnl<oown

1. Holes or Ru1s In Shoulder 2. Holes, Ruts. Bumps in Roadway COUJSION WITH OBJECT 3. Loose Material OBJECT STRUCK 4. ObstruetiooNotUghled(Deri<ness) ~ =EooS«lm ~ g:...sataly;,ml 5. Obstruction Not Mart<ed (Daylight) c. 1Itli.,. Pdo I. F""" 6. Road Under Conslructiorl o. Sosn """ J. Pijd Barner 1C<rm!rl1 7. Roadway Repairs R ~nr:'... Olltr ~ ~~I!lI:m~1 8. Obstruction - Previous Accident Sllu:Ut ,~_ Wild_

1-9_._Other__• Specify-=-_·-'-ln_R_erna_rl<s -l DRIVER 1IlS10N OBSCURED

UGHT 1. N~t Ol>scured

1 D ~'innl 2. Rain. Snow. E1c. on Wmdshield . a,"." 3. Wmdshield 0Ihe<wise Obscured By Vehicle Load2. Dawn 3. Der1mesi> S1reel or Highway Not L'ghled 4. Vislon DbsaJre<l8y Vehide Load 4. Deri<ness SL-ee1 or If'9\1way ugllted 5. Trees. GnJps. Etc.

5. Dusk ~: :kn."t

WEATHER 13 Fatigued 42 Jackl<nile 14DI ~ ~in~~

1. CIeav 4...-fog 7.~ 151mproperParl<ing 44 cargoLossorShitted 2. -fli!ini!Jg. 5 DusI 8. ~ 16 Improper Lo<>I«>u1 45 Explosion or Fire 3. Sn!.lwiz>g 6. Mis1 g. Wrnds10rm 17 FailedToSignaJ 46 Sepel1llionorUnils

f ­ ---,,.-_-I18 Olner Improper DrMng 47 Wrong Side of Road 19 Brnl<Bf. Detective 48 WlOOg Wayan One Way ~\

20 Headlighllnsufficienl or Out 49 fmpropel Backing 50 Immersion

VEHIClE MANEUVER (DRIVER INTENT) 01. Go S!reigh1 Ahead 05. MaJ;e U Turn

r-.---------------------I 02. 0Ye<1aJ<e IPass01g) O£. Slo¥J Of Stop ROADWAY CONDmONS 03. Malee Rlg!l1 Tum 07. Stlrlln Tmffi.c une

04. Make Lel1 Tum 08. Start From Parl<e<l Position

6

5

9

8

7

11

10

EHI L ii2.4.6

AlTERED VEHICLE

1. Altered Lift

3. Body 4. Tinted Windows 5. Other 6. None

23. Walking To or from Scnool 24. Walking on Sidewalf: 25. Riding on Sidewalk 26. Crosswalk nat at ln1ersection 00. Nat State<!

ADDRESS AGE SEX SAFE

EQUIP

INJURY

TYl'£ US AREA g" UJ

THROUGH WHAT AREA EJECTED?

2

PUlCE WHERE ACCIDENT OCCURRED

CounIy

<»J>lTY W Indicate the county where (he accident occurred. Do not abbreviate.

Code the two digil number representing the county using the follo",ing list:

01 Seaver 21 lrop 41 Sevier

03 Box Eklef 23 Juab 43 Summit

05 Cache 25 Kane 45 Tooele

rJ1 Carbon 'Z7 Millard 47 Uintah

09 Daggen 29 Morgan 49 Utah

11 Davis 31 PiU1e 51 Wasatch

13 Duchesne 33 Ricll 53 Washington

15 Emery 35 Salllake 55 Wayne

17 Garfield :J7 San Juan 57 Weber

19 Grand 39 Sanpete

EXAMPLE:

t3 Siw;I2UnilTllJd<

15 TrucHra::lOr . BmJi IP""'" UrnlOnlyI

32 Trude and Loog TraiIe<

• l·'.. '" .. ." . 'Jl Trador ­ 3Short TcaIefs

36 TradDr· Loog TraiI..r Shor. Trailer

3.: TlOClor· 2Tr.lgel>

35 Trodor' 2 Long Trailers

33 Trador . 2Sholl TI3iIefs

Body StyleJType Gode Enter the bOdy sty1e or type of \le'hicJe: for exampioe, 2-door sedan. sta. wag .. pickup, etc. Also pt1 the two-diIgil code desaibing the vc:hicle type in the space provided by u~ing the foIaoMngc0de-5:

28 Other, Horse-drawn carriage (Plane, eel.)

30 ATV, 3 & 4 wheelers/Snowmobile 31 Truck & 2 short trailers

(95' total length) 32 Truck and long trailer

(T5' total length) 33 Tractor and 2 short trailers

(Trailer up to 26' long) 34 Tractor - 2 trailers

(95' total length) 35 Tractor - 2 long trailers

(Permitted to 105' freeway) 36 Tractor - long trailer-short trailer

(98' total length) 37 Tractor - 3 short trailers

(Permitted to 1OS' freeway) 36 Tractor & long trailer 40 Hit & run vehicle 41 Cargo tank 42Passenger car wlvehicle in tow 43 Pickup wlveh,c1e in tow 44 Tractor wIlr3clor in tow 45 Molorhome 46 Motorhome wlboat vehicle in tow 47Flalbed I Tow Truck 48 Dump Truck 49.Concrete mi~er

50 Garbage I Refuse

02 Passenger car 03 Passenger car and house trailer 04 Passenger car and boat Os Passenger car and other trailer 06 Passenger car, public owned 07 Pickup or SUV 08 Pickup or SUV and house trailor 09 Pickup or SUV and boat 10 Pickup or SUV and other trailor 11 Pickup or SUV, Public owned 12 Pickup with camper 13 Single Unit enclosed box

(minimum 2 axles & 6 tires) 14 Truck & trailer 15 Truck IJacto<-Boblail

(power unit only) 16 Tractor and short trailer 17 Commercial Bus 16 School Bus 1g Motorcycle 20 Motorcycle Public owned 21 Motor driven bicycle

(Scooter or moped) 22 Ambulance· not emergency 23 Ambulance - efTle'geney 24 Ambulance - Public owned 25 Farm tractor andlor equipment 26 Special Mobile equipment

(Construction, Fire, UP&L, etc.)

1 Side ofllUCi<

2 Pi!j)€iWor1<

3 D<M!1

"Source of carrier NameDisposition Of Vehicle Code 1 Towed

2 /mpoullde<l 3 Ralamed by ClmerI<Iriver ~ Hiland flli\

51 Aulo TranspOf1er 52 Snowplow

27 Truck & Mobile Home

9. Eye protection used O. Helmet and eye protection used A. Shoulder belt only C. Unknown D. Child restraint used improperly E. Air bag inflated with <hOld ",..no"" used F. Helmet not wom

Safety EqUipment --tw-ot...., !he IICCIdenL Iho lho 1. Lap belt used 2. Lap & shoulder bell used 3. Belts nol used 4. Belts not installed 5. Child restraint used properly 6. Ajr bag inflated with belts 7. Air bag inflated without belts 6. Helmet worn

injury "8'ype-Cause Area

Type Indicate the type of Injury suHered in the accident. using these codes: 1 • No injury 2 • Possible injury 3 - Bruises & abrasions 4 • Broksn bones or bfge(jing wounds 5· Fatal

Gause Indicate the object that caused ll1e injury using these codes: 1 • Steering Wheel 5 - Moto<cycle haIY.lbars 2 - DashboardlWindshield 6 - Motorcycle gas tank 3 - Root 7 • Exterior vehicle part

. 4· Other Imenor 6 - External object

g. Air Bag Deployment Area Inditale the area allha v'.cf,m's llody lhal sWlered the mosl severe in"", usmg II1<!se codes:

1 • Head - 6 _ L.eg(s) 2 • Faoe 7 - Arm{s) 3 - Neck 8 _Torso 4 - Chest 9 _Unknown 5 - Back

&J,,1:a!ion • RlI in appropriate number

o.NOI e>tricaled 1- E:aricaled 9-lIMoown

Ejecllon 1 . Not ejectad 2 - Pa!1laU-, ejected 3 - FtJgy 9jecled

4. Clnvartib6e roof \4l 5. Co<M>rtibl<> roo1 <!own

Description of Cargo A. General Freight B. Household Goods C. Heavy Machinery D. Motor Vehi<;les E. Gases in Bulk F. Uvestock. Go Solids in Bulk H. Liquids in Bulk I. Explosives J. Refrigerated Foods

• List in accident descri .on

K Empty L Other M. Compressed Gases N. Flammable/Combustible uquids O. Flammable Solids: Spontaneo<ISly

combustible, water reactive P. Oxidize<s Q. Poisonous and Infectious SubslZnces R. Radioactive Materials S. Corrosives T. Other Regulated Materials (ORM)·