Involved Accident

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) Injury A	B	C	Describe Injuries	If Deceased, Enter Date of Death
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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 1

2) Vehicle 2

B) Bicyclist

P) Pedestrian

O) Other Pedestrian

POSITION IN/ON VEHICLE (Column 9) — Enter the number from this diagram which corresponds to each person’s position:

1) Driver

2-7) Passengers

8) 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

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