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Police Accident Report MV-104COV

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Police Accident Report MV-104COV PEDESTRIAN/BICYCLIST/OTHER PEDESTRIAN LOCATION APPARENT CONTRIBUTING FACTORS 1. Pedestrian/Bicyclist/Other Pedestrian at Intersection HumanHumanHumanHumanHumanHumanHumanHuman HumanHumanHuman Vehicular Vehicle 19 2. Pedestrian/Bicyclist/Other Pedestrian Not at Intersection Vehicular 2.2. Alcohol InvolvementAlcohol Involvement41. Accelerator Defective 1 PEDESTRIAN/BICYCLIST/ 3.3. Backing UnsafelyBacking Unsafely 42. Brakes Defective OTHER PEDESTRIAN ACTION 4.4. Driver Inattention/DistractionInattention/Distraction***Driver Inattention/Distraction*43. Headlights Defective 1 1. Crossing, With Signal 8. Going to/From Stopped 5.5. Driver InexperienceInexperience***Driver Inexperience*44. Other Lighting Defects 2. Crossing, Against Signal School Bus 6.6. Drugs (Illegal)Drugs (Illegal) 45. Oversized Vehicle 7.7. Failure to Yield Right-of-WayFailure to Yield Right-of-Way Vehicle 3. Crossing, No Signal, Marked 9. Getting On/Off Vehicle 46. Steering Failure 1 20 Crosswalk Other Than School Bus 8.8. Fell AsleepFell Asleep 47. Tire Failure/Inadequate 4. Crossing, No Signal or 11. Working in Roadway 9.9. Following Too CloselyFollowing Too Closely48. Tow Hitch Defective Crosswalk 12. Playing in Roadway 10.10. IllnessIllness Illness Illness 49. Windshield Inadequate 5. Riding/Walking/Skating Along 13. Other Actions in RoadwayRoadway** 11.11. Lost ConsciousnessLost Consciousness50. Driverless/Runaway Vehicle Highway With Traffic 14. Not in Roadway (Indicate)(Indicate)** 12.12. Passenger DistractionPassenger Distraction 51. Tinted Windows 2 6. Riding/Walking/Skating Along 113.13 3 Passing.... or Lane Usage ImproperPassing 60. or LaneOther Usage Vehicular*Vehicular Improper* Vehicle Highway Against Traffic 21 14.14. Pedestrian/Bicyclist/Other Environmental 2 7. Emerging from in Front of/ Pedestrian Error/Error/Confusion Behind Parked Vehicle 61. Animal’s Action 15.15. PhysicalConfusion DisabilityPedestrianPhysical Error/ Disability 62. Glare 16.16. ConfusionPrescription MedicationPrescription Medication62. Glare TRAFFIC CONTROL 63. Lane Marking Improper/ 17.17. Traffic Control DisregardedTraffic Control Disregarded 1. None 8. RR Crossing Sign 13. Maintenance Inadequate Vehicle 2. Traffic Signal 9. RR Crossing Work Area 18.18. Turning ImproperlyTurning Improperly 64. Obstruction/Debris 22 64. Obstruction/Debris 2 3. Stop Sign Flashing Light 14. Utility Work Area 19.19. Unsafe SpeedUnsafe Speed 65. Pavement Defective 4. Flashing Light 10. RR Crossing Gates 15. Police/Fire 20.20. Unsafe Lane ChangingUnsafe Lane Changing66. Pavement Slippery 5. Yield Sign 11. Stopped School Bus- Emergency 21.21. Fatigued/Drowsy Fatigued/Drowsy 67. Shoulders Defective/ 3 Red Lights Flashing 6. Officer/Guard 16. School Zone 22.22. Cell Phone (hand-held)Cell Phone (hand-held) Improper 7. No Passing 12. Construction 20. Other*Other* 23.23. Cell Phone (hands-free)Cell Phone (hands-free)68. TrafficTraffic Control Control Device Device Work Area 68. Traffic Control Device Zone 24.24. Other Electronic Device*Device**Other Electronic Device* Improper/Non-WorkingImproper/Non-Working 25.25. Outside Car Distraction*Distraction**Outside Car Distraction*69. View Obstructed/Limited LIGHT CONDITIONS New York State 226.26 6 Reaction.... to Uninvolved VehicleReaction to Uninvolved Vehicle 1. Daylight 227.27 7 Failure.... to Keep RightFailure to KeepDIRECTION Right N Vehicle NE 23 4 2. Dawn Department of Motor Vehicles 28.28. Aggressive Driving/Road Rage*Rage**Aggressive OF Driving/Road Rage* 1 3. Dusk NW POLICE ACCIDENT REPORT 29.29. Passing Too CloselyPassing Too CloselyTRAVEL: 1 4. Dark-Road Lighted 30.30. Vehicle VandalismVehicle Vandalism 8 2 5. Dark-Road Unlighted MV-104COVMV-104COV (11/13) (7/18) 31.31. Texting Texting W 7 3 E ROADWAY CHARACTER *EXPLAIN IN ACCIDENT DESCRIPTION 332.32 2 Using.... On Board Navigation DeviceUsing On Board Navigation6 5 4Device Vehicle SW 24 1. Straight and Level If a question DOESDOES NOT APPLY, NOT APPLY, 33.33. Eating or DrinkingEating or Drinking 2 2. Straight and Grade 34.34. Listening/Using HeadphonesListening/Using Headphones SE 5 enter a dash (–).( –). S 3. Straight at Hillcrest PRE-ACCIDENT VEHICLE ACTION 4. Curve and Level 5. Curve and Grade If an answer is UNKNOWN, enter 1. Going Straight Ahead 13. Passing 6. Curve at Hillcrest an “X”. 2. Making Right Turn 14. Merging 16. Making Right Turn on Red 15. Backing Vehicle 25 ROADWAY SURFACE CONDITION LOCATION OF MOST 3. Making Left Turn 18. Police Pursuit 1 SEVERE PHYSICAL 17. Making Left Turn on Red 20. Other 6 1. Dry 3. Muddy 5. Slush * 2. Wet 4. Snow/Ice 6. Flooded COMPLAINT 4. Making U Turn 0. OtherOther** 1. Head 5. Starting from Parking 2. Face 6. Starting in Traffic WEATHER 7. Slowing or Stopping 3. Eye 8. Stopped in Traffic 1. Clear 5. Sleet/Hail/Freezing Rain 4. Neck Vehicle 6. Fog/Smog/Smoke 9. Entering Parked Position 26 2. Cloudy 5. Chest 2 7 3. Rain 0. Other*Other* 10. Parked 4. Snow 6. Back/Spine 11. Avoiding Object in Roadway 7. Shoulder-Upper Arm 12. Changing Lanes 8. Elbow-Lower Arm-Hand 9. Abdomen - Pelvis LOCATION OF FIRST EVENT 27 WHICH VEHICLE OCCUPIED 10. Hip-Upper Leg 1. On Roadway 2.Off2.Off Roadway 1. Vehicle No. 1 A. All-Terrain Vehicle (ATV) O.OtherO.Other * 11. Knee-Lower Leg-Foot TYPETYPETYPE OFOF OFACCIDENTACCIDENT ACCIDENT ---- COLLISIONCOLLISION -- COLLISION WITHWITH WITH 2. Vehicle No. 2 B. Bicyclist P. Pedestrian 12. Entire Body I. In-Line Skater S. Snowmobiler 1.1. Other1. Other Motor Motor Vehicle Vehicle 7. 7. 7. Deer Deer 2.2. Pedestrian2. Pedestrian POSITION IN/ON VEHICLE 8. 8. 8. Other Other pedestrian pedestrian TYPE OF PHYSICAL COMPLAINT 3.3. Bicyclist3. Bicyclist 10.10.1100. .Other Other Object Object 1. Driver 2-7. Passengers 4.4. Animal4. Animal (Not (Not (Not Fixed)Fixed) Fixed) *** 8. Riding/Hanging on Outside 1.1. AmputationAmputation 14. Whiplash 5.5. Railroad5. Railroad TrainTrain Train 2. Concussion SAFETY EQUIPMENT USED 2. Concussion 15. Crush Injuries COLLISIONCOLLISION WITH WITH FIXED FIXED OBJECT OBJECT 3.3. InternalInternal 16. Paralysis 1. None 4. Minor Bleeding First 4. Minor Bleeding 17. Severe Lacerations11.11. 11.LightLight Light Support/UtilitySupport/Utility Support/Utility PolePole Pole 28 2. Lap Belt 5.5. SevereSevere Bleeding Bleeding 12.12. 12.Guide Guide Rail-Not Rail-Not At End At End Event 3. Harness 6.6. MinorMinor Burn Burn 25.25. 25.Guide Guide Rail-End Rail-End 4. Lap Belt/Harness 7.7. ModerateModerate Burn Burn 13.13. 13.Crash Crash Cushion Cushion 5. Child Restraint Only 8.8. SevereSevere Burn Burn 14.14. 14.Sign Sign Post Post 6. Helmet (Motorcycle Only) 9.9. FractureFracture - -Distorted Dislocation - Dislocation 15.15. 15.TreeTree Tree 7. Air Bag Deployed 10.10. ContusionContusion - -Bruise Bruise 16.16. 16.Building/Wall Building/Wall 8. Air Bag Deployed/Lap Belt 11. Abrasion 11. Abrasion 17.17. 17.Curbing Curbing Vehicle 29 8 9. Air Bag Deployed/Harness 12.12. ComplaintComplaint of of Pain Pain or Nausea 18.18. 18.FenceFence Fence 1 A. Air Bag Deployed/Lap Belt/Harness 13.13. NoneNone Visible Visible 19.19. 19.Bridge Bridge Structure Structure B. Air Bag Deployed/Child Restraint 14. Whiplash 20.20. 20.Culvert/Head Culvert/Head Wall Wall SSECONDSSECONDECONDSECOND ECOND EJECTION FROM VICTIM’S PHYSICAL AND 21.21. 21.Median-Not Median-Not At End At End EVEEVENTEEVEVENT NTNT 1 2 3 In-Line Skater/ VEHICLE EMOTIONAL STATUS 26.26. 26.Median-End Median-End 8 8 Bicyclist 27.27. 27.Barrier Barrier 4 5 6 1. Not Ejected 1. Apparent Death C. Helmet Only 2. Unconscious 22.22. 22.Snow Snow Embankment Embankment D. Helmet/Other 2. Partially Ejected 23.23. 23.Earth Earth Embankment/Rock Embankment/Rock Cut/Ditch Cut/Ditch 3. Ejected 3. Semiconscious Vehicle 7 E. Pads Only 4. Incoherent 24.24. 24.FireFire Fire HydrantHydrant Hydrant 2 30 F. Stoppers Only 5. Shock 30.30. 30.Other Other Fixed Fixed Object Object** * 8 AGE SEX NO NOCOLLISION COLLISION M/F 6. Conscious 31.31. 31.Overturned Overturned 0. Other * INJUREDINJURED TAKENTAKEN 32.32. 32.Fire/ExplosionFire/Explosion Fire/Explosion 33.33. 33.Submersion Submersion 34.34. 34.Ran Ran Off OffRoadway Roadway Only Only 8 9 10 11 12 13 14 15 16 17 BY TO 18 40.40. 40.Other Other** * MV-104COV (7/18) There are only 3 valid entries for injury code boxes 14, 15 and 16: 1. three dashes (-) meaning “does not apply” because no injury occurred. 2. three X’s meaning that an injury did occur but its complete nature is “unknown”. 3. three numeric injury codes which individually reflect the LOCATION OF MOST SEVERE PHYSICAL COMPLAINT, the TYPE OF PHYSICAL COMPLAINT and the VICTIM’S PHYSICAL AND EMOTIONAL STATUS. The injury codes in column 14, the LOCATION OF MOST SEVERE PHYSICAL COMPLAINT, are self- explanatory. Definitions of the injury codes for columns 15 and 16 are as follows: COLUMN 15 - TYPE OF PHYSICAL COMPLAINT: Column 16 — VICTIM’S PHYSICAL AND This column is used to describe the type of physical EMOTIONAL STATUS: Column 16 is used to describe injury sustained. The following are definitions of the the overall condition of the injured person. A victim’s Types of Physical Complaints for Column 15. status is defined as follows: 1. Amputation — Severed parts. 1. Apparent Death. 2. Concussion —Dazed condition as the result of a blow to the head. 2. Unconscious — Victim unaware of surroundings, and does not respond to verbal or 3. Internal — No visible injury, but signs of physical stimuli. anxiety, internal pain and thirst. 4. Minor Bleeding — Slight discharge of blood. 3. Semi-conscious — Victim not fully aware of surroundings. 5. Severe Bleeding — Steady flow of blood that is not controlled. 4. Incoherent — Lacking orderly continuity of thought. 6. Minor Burn — Reddening of the skin. 5. Shock — Depressed condition of all body 7. Moderate Burn — Reddening, blistering of skin functions, resulting from serious injury or incident. over large area. 8. Severe Burn — Reddening, blistering or charring 6. Conscious — Normal and aware of surroundings.
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