CITIZENtwoA MILAN 2010 Minnesotamotorvehicleaccidentreport
User Manual: MILAN 2010
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*SEE CODES ON REVERSE SIDE*
A
B
C
The information on this report is used to help build safer roads.
Every driver in a crash involving $1,000 or more in property damage, or injury or death, MUST COMPLETE this form and send it to Driver and Vehicle Services within 10 days.
Failure to provide this information is a misdemeanor under Minnesota Statute 169.09, subdivision 7. See reverse side for address and for data privacy information.
MINNESOTA
MOTOR VEHICLE CRASH REPORT
DRIVER’S TRAFFIC CRASH REPORT
OWNER’S FULL NAME
DRIVER’S FULL NAME
DRIVER’S LICENSE NUMBER
LICENSE PLATE NUMBER
MODELMAKE
YEAR
ADDRESS CITY
STATE OF ISSUE PARTS OF VEHICLE DAMAGED
STATE OF ISSUE DATE OF BIRTH
STATE ZIP CODE
SEX
INJURY
CODE*
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TYPE (CAR, PICKUP, VAN, SUV, MOTORCYCLE, TRUCK, ETC.) # OF OCCUPANTS
ESTIMATE REPAIR COST
GIVE FULL LIABILITY INSURANCE INFORMATION OR IT WILL BE ASSUMED YOU DID NOT HAVE INSURANCE
PLEASE
COPY
FROM
POLICY
NAME OF INSURANCE COMPANY (NOT AGENCY)
Automobile Insurance
POLICY NUMBER
Name of Policy Holder
Policy Period: from to
Address
MONTH DAY YEAR
IF MORE THAN TWO VEHICLES - FILL IN SECTION “C” ON SEPARATE FORM AND ATTACH
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DATE OF
CRASH DAY OF WEEK TIME COUNTY NAME OF CITY OR TOWNSHIP
MONTH DAY YEAR
CRASH OCCURRED
(Choose only one box below
and proceed to the right)
AT INTERSECTION
NOT AT INTERSECTION
IN PARKING LOT
LOCATION OF CRASH:
ON:
LOCATION OF CRASH:
ON:
(Street Name or Road Number)
DESCRIBE LOCATION:
AT: (Street Name or Road Number)
(Street Name or Road Number)
DISTANCE DIRECTION
(Number)
MILES
FEET FROM:
(Street Name or Road Number)
N
S
E
W
AM
PM
TOTAL # OF
VEHICLES
INVOLVED
CITY
TWP
YEAR COLOR
$
MONTH DAY YEAR
FULL NAME
DRIVER’S LICENSE NUMBER
LICENSE PLATE NUMBER
MODELMAKE
YEAR STATE OF ISSUE PARTS OF VEHICLE DAMAGED
STATE OF ISSUE DATE OF BIRTH SEX
INJURY
CODE*
TYPE (CAR, PICKUP, VAN, SUV, MOTORCYCLE, TRUCK, ETC.) # OF OCCUPANTS
ESTIMATE COST TO REPAIR
YEAR COLOR
$
OTHER
DRIVER
TYPE CRASH
COLLISION WITH A(N)
1- MOTOR VEHICLE
2- PARKED MOTOR VEHICLE
3- ROADWAY EQUIPMENT - SNOWPLOW
4- ROADWAY EQUIPMENT - OTHER
5- TRAIN
6- PEDALCYCLE, BIKE, ETC.
7- PEDESTRIAN
8- DEER
9- OTHER ANIMAL
12- COLLISION WITH OTHER
TYPE OF NON-FIXED OBJECT
13- OTHER COLLISION TYPE
NON-COLLISION
51- OVERTURN/ROLLOVER
52- SUBMERSION
53- FIRE/EXPLOSION
54- JACKKNIFE
55- LOSS/SPILLAGE NON-HAZ MAT
56- LOSS/SPILLAGE HAZ MAT
64- NON-COLLISION OF OTHER TYPE
65- NON-COLLISION OF UNKNOWN TYPE
COLLISION WITH FIXED OBJECT
21- CONSTRUCTION EQUIPMENT
22- TRAFFIC SIGNAL
23- RR CROSSING DEVICE
24- LIGHT POLE
25- UTILITY POLE
26- SIGN STRUCTURE
27- MAILBOXES
28- OTHER POLES
29- HYDRANT
30- TREE/SHRUBBERY
31- BRIDGE PIERS
32- MEDIAN SAFETY BARRIER
33- CRASH CUSHION
34- GUARDRAIL
35- FENCE (NON-MEDIAN BARRIER)
36- CULVERT/HEADWALL
37- EMBANKMENT/DITCH/CURB
38- BUILDING/WALL
39- ROCK OUTCROPS
40- PARKING METER
41- OTHER FIXED OBJECT
42- UNKNOWN FIXED OBJECT
LIGHT CONDITION
1- DAY LIGHT
2- BEFORE SUNRISE (DAWN)
3- AFTER SUNSET (DUSK)
4- DARK (STREET LIGHTS ON)
5- DARK (STREET LIGHTS OFF)
6- DARK (NO STREET LIGHTS)
7- DARK (UNKNOWN LIGHTING)
90- OTHER
WEATHER / ATMOSPHERE
3- RAIN
4- SNOW
1- CLEAR
2- CLOUDY
5- SLEET/HAIL/FREEZING RAIN
6- FOG/SMOG/SMOKE
7- BLOWING SAND/DUST/SNOW
8- SEVERE CROSSWINDS
90- OTHER
ROAD SURFACE
1- DRY
2- WET
5- ICE PACKED SNOW
6- WATER (STANDING/MOVING)
7- MUDDY
8- DEBRIS
3- SNOW
4-SLUSH
9- OILY
90- OTHER
TRAFFIC CONTROL DEVICE
1- TRAFFIC SIGNAL
2- OVERHEAD FLASHERS
3- STOP SIGN - ALL APPROACHES
4- STOP SIGN - NOT ALL APPROACHES
5- YIELD SIGN
6- OFFICER/FLAG PERSON/SCHOOL
PATROL
7- SCHOOL BUS STOP ARM
8- SCHOOL ZONE SIGN
9- NO PASSING ZONE
10- RR CROSSING GATE
11- RR CROSSING -FLASHING LIGHTS
12- RR CROSSING - STOP SIGN
13- RR OVERHEAD FLASHERS
14- RR OVERHEAD FLASHERS/
GATE
15- RR SIGN ONLY (NO LIGHTS,
GATES OR STOP SIGN)
90- OTHER
98- NOT APPLICABLE
MANNER OF COLLISION
1- REAR END
2- SIDESWIPE - SAME DIRECTION
3- LEFT TURN
4- RAN OFF ROAD - LEFT SIDE
5- RIGHT ANGLE (”T-BONE”)
6- RIGHT TURN
7- RAN OFF ROAD - RIGHT SIDE
8- HEAD ON
9- SIDE SWIPE
- OPPOSING DIRECTION
90- OTHER
WORK ZONE (CIRCLE CORRECT RESPONSE)
DID THE CRASH OCCUR IN A WORK ZONE?
IF YES, WERE WORKERS PRESENT?
YES NO
CONTINUE
REPORT ON
OTHER SIDE
WAS THERE A POLICE
OFFICER AT THE
SCENE?
IF YES, WHAT DEPARTMENT (NAME OF CITY, COUNTY OR STATE PATROL)
YES NO
BY BICYCLIST
51- RIDING WITH TRAFFIC
52- RIDING AGAINST TRAFFIC
53- MAKING RIGHT TURN
54- MAKING LEFT TURN
55- MAKING U-TURN
56- RIDING ACROSS ROAD
57- SLOWING/STOPPING/
STARTING
90- OTHER
BY PEDESTRIAN
31- CROSSING WITH SIGNAL
32- CROSSING AGAINST SIGNAL
33- DARTING INTO TRAFFIC
34- OTHER IMPROPER CROSSING
35- CROSSING IN A MARKED CROSSWALK
36- CROSSING (NO SIGNAL OR CROSSWALK)
37- FAIL TO YIELD RIGHT OF WAY TO TRAFFIC
38- INATTENTION/DISTRACTION
39- WALKING/RUNNING IN ROAD WITH
TRAFFIC
40- WALKING/RUNNING IN ROAD
AGAINST TRAFFIC
PARKED VEHICLES
21- PARKED LEGALLY
22- PARKED ILLEGALLY
23- VEHICLE STOPPED
OFF ROADWAY
ACTIONS / MANEUVERS PRIOR TO CRASH
BY VEHICLE
1- GOING STRAIGHT AHEAD
FOLLOWING ROADWAY
2- WRONG WAY INTO
OPPOSING TRAFFIC
3- RIGHT TURN ON RED
4- LEFT TURN ON RED
5- MAKING RIGHT TURN
6- MAKING LEFT TURN
7- MAKING U-TURN
8- STARTING FROM PARKED
POSITION
9- STARTING IN TRAFFIC
10- SLOWING IN TRAFFIC
11- STOPPED IN TRAFFIC
12- ENTERING PARKED POSITION
13- AVOID UNIT/OBJECT IN ROAD
14- CHANGING LANES
15- OVERTAKING/PASSING
16- MERGING
17- BACKING
18- STALLED ON ROADWAY
41- STANDING/LYING IN ROAD
42- EMERGING FROM BEHIND
PARKED VEHICLE
43- CHILD GETTING ON/OFF
SCHOOL BUS
44- PERSON GETTING ON/OFF
VEHICLE
45- PUSHING/WORKING ON VEHICLE
46- WORKING IN ROADWAY
47- PLAYING IN ROADWAY
48- NOT IN ROADWAY
DIRECTION OF TRAVEL PRIOR TO CRASH
1- NORTHBOUND
2- NORTH EASTBOUND
3- EASTBOUND
4- SOUTH EASTBOUND
5- SOUTHBOUND
6- SOUTH WESTBOUND
7- WESTBOUND
8- NORTH WESTBOUND
MY
VEHICLE OTHER
VEHICLE
MY
VEHICLE
OTHER
VEHICLE
8
7 3
65
1
4
2
N
S
EW
CLASS
ENTER NUMBER FOR CORRECT RESPONSE IN EACH BOX BELOW
YES NO
SPEED LIMIT ENTER POSTED SPEED LIMIT ( NOT YOUR TRAVEL SPEED)
ADDRESS CITY STATE ZIP CODE
ADDRESS CITY STATE ZIP CODE
FULL NAME
OTHER
OWNER
ADDRESS CITY STATE ZIP CODE
dvs.dps.mn.gov
PS 32001 - 10
CLASS
Please use BLACK ink
and CAPITAL LETTERS
As required by Minnesota Data Privacy Act you are hereby informed that the information requested on this form is collected pursuant
to statute to provide statistical data on traffic crashes. The time and place of the crash, names of parties involved and insurance
information may be disclosed to any person involved in the crash or to others persons as specified by law. This written report cannot
be used against you as evidence in any civil or criminal matter and your version of how the crash happened is confidential.
ESTIMATE COST OF REPAIR
$
SIGNATURE OF PERSON SUBMITTING REPORT IS REQUIRED
DATE OF REPORT
SIGN HERE X
DESCRIBE ACCIDENT IN SUFFICIENT DETAIL BELOW TO DISCLOSE CAUSES.
DIAGRAM WHAT HAPPENED:DESCRIBE WHAT HAPPENED:
DAMAGE TO PROPERTY OTHER THAN VEHICLES: (MAILBOX, FENCE, SIGNPOST, GUARDRAIL, ETC.)
DATE OF BIRTH (OR AGE) SEX
SEX
SEX
SEX
SEAT
SEAT
SEAT
SEAT
TYPE
TYPE
TYPE
TYPE
USE
USE
USE
USE
INJURY
INJURY
INJURY
INJURY
DRIVER >>>>>>>>>>>>>>>>>>
PASSENGER NAME
PASSENGER NAME
PASSENGER NAME
CITY
CITY
CITY
STATE
STATE
STATE
AIR BAG
AIR BAG
AIR BAG
AIR BAG
EJECT
EJECT
EJECT
EJECT
MY VEHICLE: DRIVER AND PASSENGERS INFORMATION:
DATE OF BIRTH (OR AGE)
DATE OF BIRTH (OR AGE)
DATE OF BIRTH (OR AGE)
MAIL THIS REPORT TO:
DVS / CRASH RECORDS
445 MINNESOTA STREET, SUITE 181
ST. PAUL, MN 55101-5181
DESCRIBE
PROPERTY
DAMAGED:
OCCUPANT SEAT POSITION CODES
1- DRIVER
(INCLUDE MOTORCYCLE DRIVER)
2- FRONT CENTER
3- FRONT RIGHT
4- SECOND ROW SEAT LEFT
5- SECOND ROW SEAT CENTER
6- SECOND ROW SEAT RIGHT
7- THIRD ROW SEAT LEFT
8- THIRD ROW SEAT CENTER
9- THIRD ROW SEAT RIGHT
10- OUTSIDE OF VEHICLE
11- TRAILING UNIT
12- PICKUP TRUCK BED
13- TRUCK CAB SLEEPER SECTION
14- PASSENGER IN OTHER POSITION
(INCLUDE MOTORCYCLE PASSENGER)
15- PASSENGER IN UNKNOWN POSITION
16- FRONT LEFT (NON-DRIVER)
SEAT
USE
RESTRAINT DEVICE USED
CODES
1- BELTS NOT USED
2- LAP BELT ONLY USED
3- SHOULDER BELT ONLY USED
4- LAP AND SHOULDER BELT USED
5- CHILD SEAT NOT USED
6- CHILD SEAT USED IMPROPERLY
7- CHILD SEAT USED PROPERLY
8- BOOSTER SEAT NOT USED
9- BOOSTER SEAT USED IMPROPERLY
10- BOOSTER SEAT USED PROPERLY
11- HELMET NOT USED
12- HELMET USED
EJECTION CODES
1- TRAPPED, EXTRICATED
(BY MECHANICAL MEANS)
2- TRAPPED, FREED BY
NON-MECHANICAL MEANS
3- PARTIALLY EJECTED
4- EJECTED
5- NOT EJECTED OR TRAPPED
EJECT
INJURY CODES
K- KILLED
A- INCAPACITATING INJURY
B- NON-INCAPACITATING INJURY
C- POSSIBLE INJURY
N- NO APPARENT INJURY
INJURY
TYPE
SAFETY EQUIPMENT TYPE
CODES
1- NO SAFETY EQUIP IN PLACE
2- LAP BELT
3- SHOULDER BELT
4- LAP & SHOULDER BELT
5- CHILD SAFETY SEAT
6- CHILD BOOSTER SEAT
98- NOT APPLICABLE
(MOTORCYCLE,
SNOWMOBILE, ECT.)
AIR BAG
SAFETY EQUIPMENT USED
CODES
1- DEPLOYED-FRONT
2- DEPLOYED-SIDE
3- DEPLOYED-FRONT AND SIDE
4- NOT DEPLOYED-SWITCH ON
5- NOT DEPLOYED-SWITCH OFF
6- NOT DEPLOYED- UNKNOWN
IF SWITCH ON OR OFF
90- OTHER DEPLOYMENTS
98- NOT APPLICABLE
(MOTORCYCLE,
SNOWMOBILE, ECT.)
NAME OF
PROPERTY
OWNER:
ADDRESS
INDICATE
NORTH
BY ARROW
