6 ALL INVOLVED — list the names of all persons involved in the accident, and provide the date of death if anyone was killed in, or as a result of, the accident. If more than four people were involved, complete another report. In the ALL INVOLVED section of that report, provide the required information for everyone else involved in the accident. ALL INVOLVED IN THE ACCIDENT Names of All Persons Involved 8) Which Vehicle Occupied 9) Position In/on Vehicle 10) Safety Equip Used 12) Age 13) Sex 16) InjuryA B C Describe Injuries If Deceased, Enter Date of Death Name person_1 1) Vehicle 1 2) Vehicle 2 B) Bicyclist P) Pedestrian O) Other Pedestrian person_1 1) Driver 2) Passenger 3) Passenger 4) Passenger 5) Passenger 6) Passenger 7) Passenger 8) Riding/Hanging on Outside person_1 1) None 2) Lap Belt 3) Shoulder Restraint 4) Lap Belt Restraint 5) Child Restraint Only 6) Helmet (Motorcycle Only) 7) Air Bag Deployed 8) Air Bag Deployed / Lap Belt 9) Air Bag Deployed / Shoulder Restraint A) Air Bag Deployed / Lap Belt Restraint B) Air Bag Deployed / Child Restraint C) Helmet Only D) Helmet / Other E) Pads Only F) Stoppers Only O) Other Age Sex A B C Injuries Deceased Name person_2 1) Vehicle 1 2) Vehicle 2 B) Bicyclist P) Pedestrian O) Other Pedestrian person_2 1) Driver 2) Passenger 3) Passenger 4) Passenger 5) Passenger 6) Passenger 7) Passenger 8) Riding/Hanging on Outside person_2 1) None 2) Lap Belt 3) Shoulder Restraint 4) Lap Belt Restraint 5) Child Restraint Only 6) Helmet (Motorcycle Only) 7) Air Bag Deployed 8) Air Bag Deployed / Lap Belt 9) Air Bag Deployed / Shoulder Restraint A) Air Bag Deployed / Lap Belt Restraint B) Air Bag Deployed / Child Restraint C) Helmet Only D) Helmet / Other E) Pads Only F) Stoppers Only O) Other Age Sex A B C Injuries Deceased Name person_3 1) Vehicle 1 2) Vehicle 2 B) Bicyclist P) Pedestrian O) Other Pedestrian person_3 1) Driver 2) Passenger 3) Passenger 4) Passenger 5) Passenger 6) Passenger 7) Passenger 8) Riding/Hanging on Outside person_3 1) None 2) Lap Belt 3) Shoulder Restraint 4) Lap Belt Restraint 5) Child Restraint Only 6) Helmet (Motorcycle Only) 7) Air Bag Deployed 8) Air Bag Deployed / Lap Belt 9) Air Bag Deployed / Shoulder Restraint A) Air Bag Deployed / Lap Belt Restraint B) Air Bag Deployed / Child Restraint C) Helmet Only D) Helmet / Other E) Pads Only F) Stoppers Only O) Other Age Sex A B C Injuries Deceased Name person_4 1) Vehicle 1 2) Vehicle 2 B) Bicyclist P) Pedestrian O) Other Pedestrian person_4 1) Driver 2) Passenger 3) Passenger 4) Passenger 5) Passenger 6) Passenger 7) Passenger 8) Riding/Hanging on Outside person_4 1) None 2) Lap Belt 3) Shoulder Restraint 4) Lap Belt Restraint 5) Child Restraint Only 6) Helmet (Motorcycle Only) 7) Air Bag Deployed 8) Air Bag Deployed / Lap Belt 9) Air Bag Deployed / Shoulder Restraint A) Air Bag Deployed / Lap Belt Restraint B) Air Bag Deployed / Child Restraint C) Helmet Only D) Helmet / Other E) Pads Only F) Stoppers Only O) Other Age Sex A B C Injuries Deceased INJURY (Columns 16A - C) — Check all columns(s) that apply and DESCRIBE INJURIES: A — Severe lacerations, broken or distorted limbs, skull fracture, crushed chest, internal injuries, unconscious when taken from the accident scene, unable to leave accident scene without assistance. B — Lump on head, abrasions, minor lacerations. C — momentary unconsciousness, limping, nausea, hysteria, complaint of pain (no visible injury), whiplash (complaint of neck and head pain) Enter the following codes in the appropriate columns in the section above for each person involved in the accident: WHICH VEHICLE OCCUPIED (Column 8) — Enter the appropriate number or letter 1) Vehicle 12) Vehicle 2B) BicyclistP) PedestrianO) Other Pedestrian POSITION IN/ON VEHICLE (Column 9) — Enter the number from this diagram which corresponds to each person’s position: 1) Driver2-7) Passengers8) Riding/Hanging on Outside SAFETY EQUIPMENT USED (Column 10) 1) None 2) Lap Belt 3) Shoulder Restraint 4) Lap Belt Restraint 5) Child Restraint Only 6) Helmet (Motorcycle Only) 7) Air Bag Deployed 8) Air Bag Deployed / Lap Belt 9) Air Bag Deployed / Shoulder Restraint A) Air Bag Deployed / Lap Belt Restraint B) Air Bag Deployed / Child Restraint O) Other In-Line Skater / Bicyclist C) Helmet Only D) Helmet / Other E) Pads Only F) Stoppers Only Back Next Share This Page:
