Traffic Collision Report
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Administration of Justice El Camino College Professor Ray Lewis TRAFFIC COLLISION REPORT SPECIAL NUMBER HIT & RUN CITY: JUDICIAL DISTRICT: NUMBER: CONDITIONS: INJURED: FELONY:
NUMBER HIT & RUN COUNTY: REPORTING SEAT: KILLED: MISD DISTRICT:
COLLISION OCCURRED ON: DATE: TIME: (24:00) NCIC # OFFICER ID:
MILEPOST INFORMATION: DAY OF THE WEEK: TOW AWAY PHOTOGRAPHS BY: YES NO AT INTERSECTION WITH STATE HWY REL NONE OR FEET OF YES NO PARTY 1 DRIVERS LICENSE NO. STATE: CLASS: SAFETY EQUIP VEH YR. MAKE/MODEL/COLOR LICENSE NO. STATE
DRIVER NAME (First, Middle, Last)
PED. STREET ADDRESS: OWNERS NAME: SAME AS DRIVER
PARKED CITY/STATE/ZIP OWNERS ADDRESS: SAME AS DRIVER VEH BICYCL- SEX HAIR EYES HEIGHT WEIGHT DOB RACE DISPOSITION OF VEHICLE ON ORDERS OF: IST OFFICER DRIVER OTHER OTHER HOME PHONE: BUSINESS PHONE PRIOR MECHANICAL DEFECT: NONE APPARENT REFER TO NARRATIVE CHP USE ONLY DESCRIBE SHADE DAMAGED AREA INSURANCE CARRIER: POLICY NUMBER: VEHICLE TYPE VEHICLE DAMAGE
DIR OF ON STREET OR HIGHWAY SPEED PCF ICC TRAVEL LIMIT PUC
CHP PARTY 2 DRIVERS LICENSE NO. STATE: CLASS: SAFETY EQUIP VEH YR. MAKE/MODEL/COLOR LICENSE NO. STATE
DRIVER NAME (First, Middle, Last)
PED. STREET ADDRESS: OWNERS NAME: SAME AS DRIVER
PARKED CITY/STATE/ZIP OWNERS ADDRESS: SAME AS DRIVER VEH BICYCL- SEX HAIR EYES HEIGHT WEIGHT DOB RACE DISPOSITION OF VEHICLE ON ORDERS OF: IST OFFICER DRIVER OTHER OTHER HOME PHONE: BUSINESS PHONE PRIOR MECHANICAL DEFECT: NONE APPARENT REFER TO NARRATIVE CHP USE ONLY DESCRIBE SHADE DAMAGED AREA INSURANCE CARRIER: POLICY NUMBER: VEHICLE TYPE VEHICLE DAMAGE
DIR OF ON STREET OR HIGHWAY SPEED PCF ICC TRAVEL LIMIT PUC
CHP PARTY 3 DRIVERS LICENSE NO. STATE: CLASS: SAFETY EQUIP VEH YR. MAKE/MODEL/COLOR LICENSE NO. STATE
DRIVER NAME (First, Middle, Last)
PED. STREET ADDRESS: OWNERS NAME: SAME AS DRIVER
PARKED CITY/STATE/ZIP OWNERS ADDRESS: SAME AS DRIVER VEH BICYCL- SEX HAIR EYES HEIGHT WEIGHT DOB RACE DISPOSITION OF VEHICLE ON ORDERS OF: IST OFFICER DRIVER OTHER OTHER HOME PHONE: BUSINESS PHONE PRIOR MECHANICAL DEFECT: NONE APPARENT REFER TO NARRATIVE CHP USE ONLY DESCRIBE SHADE DAMAGED AREA INSURANCE CARRIER: POLICY NUMBER: VEHICLE TYPE VEHICLE DAMAGE
DIR OF ON STREET OR HIGHWAY SPEED PCF ICC TRAVEL LIMIT PUC
CHP PREPARER’S NAME: REVIEWER’S NAME: DATE REVIEWED: Administration of Justice El Camino College Professor Ray Lewis
Administration of Justice El Camino College Professor Ray Lewis TRAFFIC COLLISION CODING DATE OF COLLISION: TIME: NCIC NUMBER: OFFICER I.D. NUMBER:
OWNERS NAME/ADDRESS: NOTIFIED PROPERTY YES NO DAMAGE DESCRIPTION OF DAMAGE:
SEATING POSITION SAFETY EQUIPMENT EJECTED FROM VEH. OCCUPANTS Air bag deployed M/C BICYCLE–HELMET None in Vehicle Air bag not deployed Not ejected Unknown Other Driver Fully ejected 1 2 3 4 5 Lap Belt Used Not Required No Partially ejected 6 7 Shoulder Harness Used CHILD RESTRAINT Yes Unknown Shoulder Harness Not Used In vehicle used Lap/Shoulder Harness Used In vehicle not used Passenger Lap/Shoulder Harness Not Used In vehicle use unknown No Passive Restraint Used In vehicle improper use Yes Passive Restraint Not Used None in vehicle ITEMS MARKED BELOW WHICH ARE FOLLOWED BY AN ASTERISK (*) SHOULD BE EXPLAINED IN THE NARRATIVE. PRIMARY COLLISION FACTOR LIST TRAFFIC CONTROL DEVICES 1 2 3 TYPE OF VEHICLE 1 2 3 MOVEMENT PROCEDING COLLISION NUMBER OF PARTY AT FAULT VC Section Violated Cited Controls functioning Passenger car/Station wagon Stopped Yes Controls not functioning* Passenger car with trailer Proceeding Straight No Controls obscured Motorcycle/Scooter Ran Off Road Other Improper Driving No controls present/factor* Pickup or panel truck Making Right Turn Other Than Driver TYPE OF COLLISION Pickup/Panel truck with trailer MAKING LEFT TURN Unknown * Head-on Truck or Truck tractor Making U Turn Fell Asleep * Sideswipe Truck/Truck tractor with trailer Backing Rear End School bus Slowing/Stopping WEATHER (Mark 1 to 2 items) Broadside Other Bus Passing Other Vehicle Clear Hit Object Emergency Vehicle Changing Lanes Cloudy Overturned Hwy. Const. Equipment Parking Maneuver Raining Vehicle/Pedestrian Bicycle Entering Traffic Snowing Other: Other Vehicle Other Unsafe Turning Fog/Visibility ft MOTOR VEHICLE INVOLVED WITH Pedestrian Xing Onto Opposite Lane Other: Non-collision Moped Parked Wind Pedestrian Merging Other Motor Vehicle OTHER ASSOCITED FACTOR (Mark 1 to 2 items) TRAVELING WRONG WAY LIGHTING Motor Veh. on other roadway VC Section Violation: Cited OTHER: Daylight Parked motor vehicle Yes Dusk/Dawn Train No Dark – Street Lights Bicycle VC Section Violation: Cited Dark – No Street Lights Animal: Yes Dark – Street Lights no Fixed Object: No functioning Other Object: VC Section Violation: Cited Yes SOBRIETY – DRUG PHYSICAL (Mark 1 to 2 items) No Had Not Been Drinking ROADWAY SURFACE Vision Obscurement HSD – UNDER INFLUENCE Dry Inattention Hsd – Not Under Unflu. * Wet Stop and GoTraffic Hsd – Impairment Unk.* Snowy – Icy Entering/Leaving ramp Under Drug Influ.* Slippery (muddy, Oily, etc.) Previous collision Impairment – Physical * Unfamiliar with road Impairment Not Known ROADWAY CONDITIONS Defective Veh. Equip Cited NOT APPLICABLE (Mark 1 to 2 items) SLEEPY / FATIGUED Yes Holes, deep ruts* PEDESTRIANS ACTION
No Loose material on Rdwy* No pedestrian involved Uninvolved vehicle SPECIAL INFORMATION Obstruction on Rdwy* Crossing in Crosswalk at Other: Hazardous Material Construction – Repair zone intersection None Apparent Reduced Roadway width Crossing – not a crosswalk Runaway Vehicle Flooded* In Road – Includes Shoulder Other* Not in Road No unusual conditions Approach/Leaving School Bus Administration of Justice El Camino College Professor Ray Lewis SKETCH MISCELLANEOUS
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