9.

10. 11. 12. 13. 14. 15.

LEFT & RIGHT TURN

LEFTTURNS

NO TURNS

RIGHTTURNS

16. 17. 18. 19. 20.

Environmental and Roadway Conditions

L. Surface Condition1. Dry2. Wet3. Snow4. Ice5. Sand, Mud, Dirt, Oil,

Gravel

G. Light1. Daylight2. Dawn3. Dusk4. Dark - Lighted

Roadway5. Dark - Roadway

Not Lighted6. Dark - Unknown

Roadway Lighting7. Other8. Not Reported9. Unknown

F. Weather Conditions1. Clear2. Cloudy3. Fog, Smog, Smoke4. Rain5. Sleet, Hail (Freezing Rain or

Drizzle)6. Snow7. Severe Crosswinds8. Blowing Sand, Soil, Dirt, Snow9. Other - Explain in Narrative

10. Not Reported11. Unknown

H. Road Characteristics1. Not at a Junction2. Four-way Intersection3. T-intersection4. Y-intersection5. Traffic Circle / Roundabout6. Five-point, or More7. On Ramp

B. Vehicle 1 Collided With1. Pedestrian2. MV in Traffic3. MV Parked4. RR Train5. Pedalcycle6. Deer7. Moose8. Other Wild Animal9. Domestic Animal

10. Snowmobile11. Other Movable Object

M. Contributing Road Conditions1. None2. Road Surface Condition

(Wet, Icy, Snow, Slush, etc.)3. Debris4. Rut, Holes, Bumps5. Work Zone

(Construction/Maintenance/Utility)6. Worn, Travel-polished Surface7. Obstruction in Roadway8. Traffic Control Device Inoperative,

Missing, or Obscured9. Shoulders (None, Low, Soft, High)

10. Non-highway Work11. Other - Explain in Narrative12. Not Reported13. Unknown

N. Police Photo/VideoRecording Taken

1. Yes2. No

A. Crash Type1. Property Damage Only2. Injury3. Fatal

K. Road Type1. Blacktop2. Gravel3. Dirt Trail4. Concrete5. Other6. Unknown

J. Road Design2. Hillcrest3. Bottom of Hill(Sag)

4. Level5. Unknown6. Uphill

I. Road Align1. Straight4. Unknown5. Curve Left6. Curve Right

E. Traffic Control1. No Control2. Stop Signs on Cross St Only3. Stop Signs on Mainline Only4. All-way Stop Signs5. All-way Flasher (Red on Cross Street)6. All-way Flasher (Red on Mainline)7. All-way Flasher (Red on All)8. Yield Signs on Cross Street Only9. Yield Signs on Mainline Only

10. Traffic Signal (Normal Operation)11. Traffic Signal (Flashing)12. Officer13. Flagman14. Other - Explain in Narrative15. Unknown

8.

1stCollision

2ndCollision

12. Overturned13. Other, Non-collision14. Guard Rail, Curb15. Tree16. Pole, Sign17. Ledge, Boulder18. Other Fixed Object19. Motor Driven Cycle20. Motorcycle21. Work Zone Equipment22. Unknown

8. Off Ramp9. Crossover

10. Driveway11. Railway Grade Crossing12. Shared-use Paths or Trails13. Parking Lot14. Unknown15. Other - Explain in Narrative

6. Water (Standing, Moving)7. Slush8. Other - Explain in Narrative9. Not reported

10. Unknown

Pedestrian/Cycle Action Codes (used on Page 3)1. Improper crossing2. Darting3. Lying and/or illegally in roadway4. Failure to yield right of way5. Not visible (dark clothing)6. Inattentive (talking, eating, etc.)7. Failure to obey traffic signs, signals, or officer8. Wrong side of road

9. Other - Explain in Narrative10. Unknown

Pedestrian/Cycle Location Codes (used on Page 3)1. Marked Crosswalk at Intersection2. At Intersection but No Crosswalk3. Non-intersection Crosswalk4. Driveway Access5. In Roadway6. Not in Roadway7. Median/Crossing Island9. Shoulder/Roadside

10. Sidewalk11. Within 10 Feet of Roadway (but Not Shoulder,

Median, Sidewalk, or Island)12. Beyond 10 Feet of Roadway (Within Trafficway)13. Outside Trafficway/Non-Trafficway Area14. Shared-use Path or Trails

Overlay 1

D. Direction of Collision1. Rear End2. Head On3. Same Direction Sideswipe4. Opp Direction Sideswipe5. Rear-to-rear6. Single Vehicle Crash7. Other - Explain in Narrative

7. Downhill

11. No Improper Action12. Disabled Vehicle Related (working on,pushing, leaving/approaching).

13. Entering/Exiting Parked/Standing Vehicle14. Improper Turn/Merge15. Improper Passing

15. Other16. Unknown

TA-VA-01 (d) 1M 1/17 MAW

INSTRUCTIONS FOR COMPLETING THE VERMONT UNIFORM CRASH REPORT

# Instructions for completing the Uniform Crash Report may be found in theInvestigators Guide for Completing the Uniform Crash Report at the Agencyof Transportation Website (http//www.vermontcrashmanualonline.com).

# Each form provides space for the reporting of information relative to twovehicles or a vehicle and a pedestrian.

# Each form also provides space for the reporting of information relative toseven involved persons.

# Whenever the number of vehicles or involved persons exceeds the spaceavailable on the form, additional forms must be utilized.

# When using additional forms, the third, fourth and fifth vehicles beingreported will always be reported as Vehicles #3, #4 and #5 respectively. Thepreprinted Vehicle 1 and Vehicle 2 should be crossed out and the correctvehicle number substituted accordingly.

# Use United States Postal Service Standard State Abbreviations when enteringsuch information.

# Use the following data entry sequence during the crash investigation:

1. Complete Page 1 (face page of the report)2. Use Overlay 1 to enter data into unshaded boxes3. Use Overlay 2 to enter data into shaded boxes, complete

relevant sections4. Complete Page 3, relevant sections5. Complete crash narrative on Page 2, if necessary6. Complete crash diagram on Page 4, if necessary

# Be sure to provide each operator with a colored copy of Page 1 of the crashreport.

# Be sure that overlay arrows are correctly aligned with the shaded andunshaded boxes on Page 1 of the crash form.

# Be sure to place the cardboard separator between the form being used and thefollowing form in the pad to prevent inadvertent data transfer.

Additional Operator Information

Additional Vehicle Information - All Vehicles

O. Apparent Operator Condition1. Apparently Normal2. Physical Impairment3. Emotional (e.g., Depressed, Angry,

Disturbed)4. Illness/Fainted5. Fell Asleep, Fatigued, etc6. Under the Influence of

Medications/Drugs/Alcohol7. Had Been Drinking8. Other - Explain in Narrative9. Unknown

Q. Defective Equipment1. Brakes 7. Engine2. Tires 8. Glass3. Steering 9. Other - Explain in Narrative4. Front Lights

10. Unknown 5. Rear Lights 11. No defects 6. Exhaust

R. Vehicle Configuration1. Bus (Seats more than 15 Including Driver)2. Light Truck3. Passenger Car4. Bus (Seats 9 to 15 Including Driver)5. Single Unit Truck: 2 Axle, 6 Tires6. Single Unit Truck: 3 or More Axles7. Truck/Trailer8. Truck Tractor (Bobtail)9. Tractor/Semi-trailer

10. Tractor/Doubles11. Other - Explain in Narrative12. Unknown Heavy Truck13. Any 4-tire Vehicle with Placard

Only Large Truck/Bus ( Commercial Motor Vehicle)S. Cargo Body Type

1. Bus (Seats more than 15 Including Driver) 2. Bus (Seats 9-15 Including Driver)3. Van/Enclosed Box4. Cargo Tank5. Flatbed/Stake Body6. Dump7. Concrete Mixer8. Auto Transporter9. Garbage/Refuse

10. Hopper (Grain, Chips, Gravel)11. Pole12. Not Applicable13. Other - Explain in Narrative14. Intermodal

T. Sequence of Events1. Ran off road2. Jackknife3. Overturn (rollover)4. Downhill runaway5. Cargo loss or shift6. Explosion or fire7. Separation of units8. Collision involving pedestrian9. Collision involving motor

vehicle in transport10. Collision involving parked

motor vehicle11. Collision involving train

12. Collision involving pedacycle13. Collision involving animal14. Collision involving fixed object15. Collision involving other movable object16. Noncollision: Cross median/centerline17. Noncollision: Equipment failure (brake, tires, etc)18. Noncollision: Other19. Noncollision: Unknown20. Collision with work zone maintenance equipment21. Collision with unknown movable object22. Other - Explain in Narrative

Veh 1Veh 2

Event 1

Event 2

Event 3

Event 4

Veh 1

Veh 2

Primary

Secondary

Primary

Secondary

Veh 1 Veh 2

P. Contributing Circumstances - Driver1. No Improper Driving2. Failed to Yield Right of Way

3. Disregarded Traffic Signs, Signals, Markings

4. Exceeded Authorized Speed Limit5. Driving Too Fast for Conditions6. Made an Improper Turn7. Wrong Side or Wrong Way8. Followed Too Closely9. Failure to Keep in Proper Lane.

10. Operating Vehicle in Erratic, Reckless, Careless, Negligent or Aggressive Manner

11. Swerving or Avoiding Due to Wind, Slippery Surface, Vehicle, Object, Non-

motorist in Roadway, etc 12. Under the Influence of Medication/

Drugs/Alcohol13. Visibility Obstructed14. Inattention

Operator 1

Operator 2

Veh 1

Veh 2

Veh 2

Veh 1

Event 1

Event 2

Event 3

Event 4

Overlay 2

U. Perceived Race-Driver1. Asian or Pacific Islander2. Black3. Hispanic 4. Native American or Alaskan Native5. White

Operator 1

Operator 2

16. Fatigued, Asleep17. Operating Defective

Equipment18. Other Improper Action20. UnknownDISTRACTED:21. Not Distracted22. Manually Operating an

Electronic Communication Device (texting, typing,dialing)

23. Talking on Hands FreeElectronic Device

25. Other Activity, Electronic Device26. Passenger27. Other Inside Vehicle28 . Other Outside Vehicle

24. Talking on Hand-HeldElectronic Device

14. Tractor/Triple15. Logging16. Vehicle Towing Another Vehicle

23. Cross Centerline24. Cross Median

INSTRUCTIONS FOR LARGE TRUCK/BUS (COMMERCIAL MOTOR VEHICLE )

General Instructions

OR

OR

OR

OR

AND

Complete relevant Large Truck/Bus ( CMV ) sections of the form when the crash involves:

Complete relevant sections of the form when the crash involves a vehicle as listed above and results any of the following:

Any truck having a gross vehicle weight rating (GVWR) of more than 10,000 pounds or a gross combination weight rating (GCWR) over 10,000 pounds used on public highways;

Any motor vehicle designed to transport 9 or more people, including the driver;

Any vehicle displaying a hazardous materials placard (regardless of weight).

One or more fatalities [including person(s) who die within 30 days of the crash];

One or more persons injured and transported from the scene for immediate medical attention;

One or more motor vehicles were disabled as a result of the crash and transported away from the scene by a tow truck or other vehicle.

Relevant Sections of Form

Crashes involving local, state and federal gove rnment owned vehicles should be reported as Large Truck/Bus vehicle crashes. Rented or lease vehicles that meet any of the above vehicle types must also be reported as Large Truck/Bus motor vehicles.

If “Comm Veh” box has been checked in the “Vehicle” section(s) of Page 1, then

Complete Overlay 2: “Large Truck/Bus (Commercial Vehicle) ” section, boxes R, S, & T, then

Complete Page 3: “Large Truck/Bus ( Commercial Vehicle)” section

Plate TypesA. AutosB. TrucksC. TrailersD. Farm Trucks

E. Moveable Dealer PlatesF. Handicapped: Plate/PlacardG. ATV, Moped, MotorcycleH. Special - Unspeci ed

I. BusJ. Municipal: Auto, Truck, BusK. VT State Government: Auto, TruckL. Out of State - Auto

M. Out of StateTruck

N. Out of StateOther

******************************************************************

License Class (Lic Class)1. OPER (D) 3. JR 5. CDL B 7. NONE2. CDL A 4. LP 6. CDL C 0. Other

Restrictions (Restr)enoN.0

D-Prosthetic Aid M-No Class A Passenger Vehicle

Large Truck/Bus (CMV)

G-Limit to Daylight Only P-No Passengers in a CMV Bus

B-Corrective Lenses K-CDL Intrastate Only V-Medical VarianceC-Mechanical Devices(adaptive devices) L-No Air Brakes Equipped CMV X-Cargo in a CMV Tank Vehicle

Y-Three Wheel MTC OnlyE-No Manual Transmission Equipped CMV N-Class A and B Passenger Vehicle Z-No Full Air Brake Equipped CMV

A-With Licensed Driver 25 or Older J-Other-See Separate Card U-Ignition Interlock Device

STATE OF VERMONT UNIFORM CRASH REPORT Reporting Agency Date

Street Address

Distance (From Nearest Int. St) Direction (From Nearest Int. St)

N S E W

.nwonknU tsaL I .MtsriF

A piZetatSnwoT/ytiCsserdd

Telephone xeSBOD

.I.MtsriF

Address .leTpiZetatSnwoT/ytiC

Insurance Co. Policy No.

State

VIN Registration No.

Vehicle Yr.

Make Model

Plate Type

1

2 3 4

5

678 Towed By Towed Due to Disabling Damage: Y N

Other Persons and Witnesses Involved Address

Reporting Officer A etaDdevorpp

Feet Miles

Direction of Travel

N S E W

City/Town

Incident Number Time

TH#_____

Intersection with Nearest Intersecting St or Landmark

VEHICLE #1 License #

State

OPERATOR CDL

Y N

Lic Class

Restrictions

OWNER

Same as Operator Name: Last

Est. Speed Comm Veh Y N

If yes,see Overlay 2and Page 3

Seat Belt Y N

VEHICLE

Date

Non-vehicle Property DamageOwner A enohPsserdd

Damage Description

VT#____ US#____ I - ____

.I.MtsriF

Address City/Town State Zip Tel.

Insurance Co. Policy No.

OPERATOR

OWNER

Same as Operator Name: Last

Mile Marker

Posted Speed

(For investigated crashes see Page 3.)Name

Name:

.I.MtsriF

Address City/Town State Zip

xeSBODenohpeleT

VEHICLE #2 License #

State Lic Class

Restrictions

Towed By Towed Due to Disabling Damage: Y N

VEHICLE

9 Hood10 Roof11 Trunk12 Undercarriage13 Total

1

2 3 4

5

67

Direction of Travel N S E W

Est. Speed 9 Hood10 Roof11 Trunk12 Undercarriage13 Total

8

Phone

If yes,see Overlay 2and Page 3

B1

B2

D

E

F

G

H

J

K

I

L

M

N

O1

O3

O4

Q1

Q2

Q3

R1

R2

T1

T2

T3

T4

P1

P2

P3

P4

Q4

Q5

Q6

S1

S2

T5

T6

T7

T8

Name:

Last Unknown

No Driver Y N

No Driver Y N

Operators involved in an accident which results in injury, death, or total property damage equal to $3,000 or more, must file a report with DMV

Operator Report Required * Y N

VIN Plate Type Registration No.

State Vehicle Yr.

Model Make

Seat Belt Y N

CDLY N

Comm Veh Y N

*

DOB

OR

ATV Y N Snowmobile Y N

ATV Y N Snowmobile Y N

U1

U2

A

O2

14 No Damage Parked

Parked14 No Damage

Coordinates:

Longitude/Easting

Latitude/Northing

Crash NarrativeIncident Number _____________________

Reporting Agency ____________________

Officer's Signature _________________________

Page 2

Additional Sheets Attached: Y N

4. Possible Injury (C)

2. SuspectedSerious Injury (A)

Transp.

EMS

18. Lighting

Incident Number

Vehicle NumberLARGE TRUCK/BUS

Carrier's Identification Numbers

US DOT MC/MX Interstate Carrier

Carrier's Name

Carrier's Address City State Zip

Source:(Check all that apply) Vehicle Side Shipping Papers Driver Carrier

Vehicle Information

Axles on Vehicle (Including Trailers) lbs kgor

Length of Vehicle (Incl. Trailer) ft or meters Length of Trailer ft or meters

Trailer 1 License Number State Trailer 1 VIN

Hazardous Material Spill:Placard: Name or 4 Digit Number from Diamond or Box Small Number from Bottom

Non-commercial Trailer

Year Make Model Plate No. State

Year Make Model Plate No. State

Operator Citation Information

Alcohol Test1. None Given2. Refused3. Blood/Serum4. Urine5. Other6. Breath Preliminary7. Breath Evidentiary

Citations Issued - Veh

Ticket # Violation Code

Citations Issued - Veh

Ticket # Violation Code

Drug Test1. None Given

3. Blood/Serum4. Urine5. Other

2. Refused

Drug Test Result7. Pending

9. Central Nervous

10. Hallucinogens

8. Central Nervous

EMS Run number EMS Agency Destination Hospital

Operators, Occupants, Pedestrians, Cyclists - Excluding Witnesses

Name Veh# Type Sex Age Seat Injury EjectRestr/Safety

AirBag Extract

P/C-P/C-

Action Location

CODESType

1. Operator2. Occupant3. Pedestrian4. Bicyclist5. Unknown

Seat Location

1

4

7

2

5

8

3

6

9

10

11

12

Pedestrian/Cyclist Codes on Overlay 1

Injury Restraint/Safety Equipment Ejected Airbag Deployed1. Fatality (K)

3. Suspected

5. No Injury (O)6. Unknown

0. Unknown1. None Used2. Shoulder Belt Only3. Lap Belt Only4. Shoulder and Lap Belt5. Child Safety Restraint

10. DOT CompliantHelmet w/out EyeProtection

9. DOT CompliantHelmet w/Eye Protection

8. Not Reported

1. Not Ejected2. Totally Ejected3. Partially Ejected4. Not Applicable

5. Unknown Extracted

1. Yes2. No3. Unknown

1. Yes2. No

1 2

1

2

Page 3

11. Dissociative

(Commercial Vehicle)

7. Untimely Death

Trailer 2 License Number State Trailer 2 VIN

Vehicle

Vehicle

GVWR GCWROR

Intrastate Carrier Government

System Depressants

System Stimulants

Anesthetics

12. NarcoticAnalgesics

13. Inhalants14. Cannabis15. None

Detected

11. Non-DOT CompliantHelmet

12. Improper-ChildRestraint

13. Improper-seatbelt

14. No Helmet

Medical EMS

1. Yes

Transport

2. No

Alcohol Test Test Result 0. BAC DUI Arrest? Drug Test Drug Test Result

Alcohol Test Test Result 0. BAC DUI Arrest? Drug Test Drug Test Result

Alcohol Test Test Result 0. BAC DUI Arrest? Drug Test Drug Test Result

15. Helmet16. Protective

Pads Used17. Reflective

Clothing (jacket,backpack, etc.)

19. Other20. Not Applicable

Alcohol Test Test Result 0. BAC DUI Arrest? Drug Test Drug Test Result

6. Saliva

Minor Injury (B)

Crash DiagramIncident Number _____________________

Page 4

Additional Sheets Attached: Y N

Vehicle Moved Y N

Indicate Northby Arrow