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New Mexico UCR Form

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New Mexico UCR Form CRASH STATE OF NEW MEXICO INVESTIGATION UNIFORM CRASH REPORT SH 10074 Rev July 2018 NMDOTUCR REPORTING DEPARTMENT Hit-and-Run E July 2018 On Pvt Property FATAL PROPERTY UNDER $500 Case Number: DAMAGE School Bus Directly Involved Secondary Crash School Bus Indirectly Involved INJURY ONLY $500 OR MORE Commercial Vehicle Involved Agency Code: CAD Num: CRASH DATE (MM/DD/YYYY) MILITARY TIME CITY OCCURRED IN COUNTY Sun M Tu W Th F Sat OCCURRED ON: (Route No. or Name, Address) AT INTERSECTION WITH: OTHER FEET N NE NW S SE SW E W MILEPOST - PERMANENT LANDMARK - COUNTY LINE – INTERSECTION LAT: LOCATION MILES LONG: Work Zone-Construction TRIBAL LAND? FIRST Collision w/Motor Vehicle Collision w/Animal ANALYSIS On Roadway Collision w/Person CRASH Work Zone-Maintenance HARMFUL Collision w/Fixed Object CODE: Off Roadway Non-Collision OCCURRED Yes No EVENT Non-Trafficway Work Zone-Utility Collision w/Other Non-Fixed Object LOCATION (FHE) Other (Specify in Narrative) OF FHE: VEHICLE NO. MV Unit Type N NE NW S SE SW E W On: Left Scene of Crash Posted Speed Safe Speed HEADED 1 Yes No Driver’s Full Name (Last, First, Middle) Address Driver’s License Number State Type CDL Status Restrictions Endorsements Expires Interlock City/State ZIP Code Phone Date of Birth - MM/DD/YYYY Occupation Incident Responder Sex Injury OP OP Used Airbag Seat Pos. Race Ejected Med Trans Age (M/F) Code Code Properly Deploy EMS # Seat Pos. Occupant’s Name (Last, First, Middle) Occupant’s Address (City, State, ZIP) Vehicle Yr. Vehicle Make Model Color Body Style Cargo Body Type Vehicle Use (1) Vehicle Use (2) Vehicle Use (3) Towed? Damage Severity Extent 1 2 3 4 5 Number of Occupants: ________ Yes No Heavy Disabled License Yr. State License Plate Number VIN Moderate 12 6 Towed due to Slight Functional None Minor disabling Unknown None 11 10 9 8 7 USDOT# State # Carrier Towed Towed To damage? All Areas Type By Property Code Yes No Fire Top Undercarriage Number Vehicle Weight Rating/Gross Combination Weight Rating HazMat Placard Hazmat Placard 4 digit # OR Hazmat Name AND 1 digit # Hazmat Released? (cargo only) of Axles 10,000 lbs. 10,001 lbs. Greater than (Cargo only) or less to 26,000 lbs. 26,000 lbs. Yes No NA Yes No Vehicle No. Carrier’s Name Carrier’s Address (Street/PO Box, City, State) Carrier’s ZIP Owner’s Name Owner’s Company Name Owner’s Address (Street/PO Box, City, State) Owner’s ZIP Owner’s Telephone Insured By: (Name of Company) Policy Number Trailer or Towed Type Year Make License Yr. License State License Number Vehicles (1) Trailer or Type Year Make License Yr. License State License Number Trailer or Towed Type Year Make License Yr. License State License Number Towed vehicles (2) Vehicles (3) VEHICLE NO. MV Unit Type N NE NW S SE SW E W On: Left Scene of Crash Posted Speed Safe Speed HEADED 2 Yes No Driver’s Full Name (Last, First, Middle) Address Driver’s License Number State Type CDL Status Restrictions Endorsements Expires Interlock City/State ZIP Code Phone Date of Birth - MM/DD/YYYY Occupation Incident Responder Sex Injury OP OP Used Airbag Seat Pos. Race Ejected Med Trans Age (M/F) Code Code Properly Deploy EMS # Seat Pos. Occupant’s Name (Last, First, Middle) Occupant’s Address (City, State, ZIP) Number of Occupants: ________ Vehicle Yr. Vehicle Make Model Color Body Style Cargo Body Type Vehicle Use (1) Vehicle Use (2) Vehicle Use (3) Towed? Damage Severity Extent 1 2 3 4 5 Yes No Heavy Disabled License Yr. State License Plate Number VIN Moderate 12 6 Towed due to Slight Functional None Minor disabling Unknown None 11 10 9 8 7 USDOT# State # Carrier Towed Towed To damage? All Areas Type By Property Code Yes No Fire Top Undercarriage Number Vehicle Weight Rating/Gross Combination Weight Rating HazMat Placard Hazmat Placard 4 digit # OR Hazmat Name AND 1 digit # Hazmat Released? (cargo only) of Axles 10,000 lbs. 10,001 lbs. Greater than (Cargo only) or less to 26,000 lbs. 26,000 lbs. Yes No NA Yes No Carrier’s Name Carrier’s Address (Street/PO Box, City, State) Carrier’s ZIP or PEDESTRIAN - OTHER NON-MOTORIST Owner’s Name Owner’s Company Name Owner’s Address (Street/PO Box, City, State) Owner’s ZIP Owner’s Telephone Insured By: (Name of Company) Policy Number Trailer or Towed Type Year Make License Yr. License State License Number Vehicles (1) Trailer or Type Year Make License Yr. License State License Number Trailer or Towed Type Year Make License Yr. License State License Number Vehicle No. Towed vehicles (2) Vehicles (3) Crash Report Number STATE OF NEW MEXICO UNIFORM CRASH REPORT SHEET Case Number NM Statute 66-7-209 OF SHEETS LIGHTING WEATHER ROAD COND ROAD SURFACE TRAFFIC CONTROL ROAD CHARACTER RELATION Work Zone Information (Check 1) (Check up to 2) (Check 1 for each) (Check 1 for each) (Check 1 for each) (Check 1 for each) TO JUNCTION Non-Junction Location: Clear Daylight Dry Straight Acceleration/ Type of Work Zone: Lane Markers No-Passing Zone Blowing Sand, Wet Curve Left Deceleration Lane Workers Present: Dawn Soil, Dirt Paved Stop Sign Crossover Snow Curve Right Law Enforcement Present: Blowing Snow Unstriped Crossover Traffic Signals GRADE Dusk Slush Related ROAD DESIGN (Check 1 for each per section) Cloudy Paved (Check 1 for each) Ice Center Stripe Yield Sign Driveway Dark -Lighted Fog,Smog, Driveway Level 1 Lane Alley Smoke Loose Paved Center R.R. Xing Device Access Related & Edgeline (sign,signal,gate,etc.) Dark -Not Lighted Raining Material Hillcrest Entrance/Exit 2 Lanes Full Access Control WEATHER Unpaved Ramp Severe Oil All Way Stop Uphill 3 Lanes – Dark -Unknown Lighting Crosswind Entrance/Exit One-Way Standing or Flashers Downhill Ramp Related 4 + Lanes Sleet or Ramp Other Moving Water Intersection Hail No Controls Dip Undivided Two-way, Divided ROAD Other Intersection Unknown or Snowing School Zone Intersection Type Related Physical Two-way, Not Divided Sign/Device (Check 1) Divider Not Reported Freezing Rain Railway Grade Two-way, Not Divided or Freezing Drizzle Other Not an Intersection Crossing Painted Continuous Left Turn Lane Divider(>4ft) Wind (Specify in narrative) Five-Point or More Shared-Use Undeveloped Four-Way T Int Path or Trail Physical Other Other (Specify Inoperative/ Through Barrier in narrative) Missing Roundabout Y Int Traffic Circle L Int Roadway No Shoulder APPARENT CONTRIBUTING FACTORS DRIVERS’ ACTIONS SEQUENCE OF EVENTS (Check 1 or more for each) (Check 1 or more for each) (See event codes) DRIVER Improper lane change Defective Tires Avoid no contact - other Improper overtaking Exhaust System Going Straight Stopped for traffic FIRST Avoid no contact - vehicle Made improper turn Inadequate brakes Overtaking/Passing EVENT Cell phone No driver error Lights (head, signal, tail) Right Turn Stopped for Disregarded traffic signal Other improper driving Mirrors sign/signal Left Turn Driver distracted by texting Passed stop sign Other mech. Defect Start in SECOND Driver distracted by talking on cell phone Pedestrian error Suspension U Turn traffic lane EVENT Driver distracted by talking on hand free device Speed too fast for conditions Wheels Slowing Start from Driver distracted by passenger Under influence of alcohol Windows/Windshield park Backing THIRD EVENT Driver distracted by other activity Under influence of drugs or medication Wipers Negotiating a Curve Operated MV EVENT Driver Inattention ENVIRONMENT ROADWAY in Reckless Drove left of center Animal(s) in roadway Backup - prior crash Changing Lanes or Aggressive Excessive Speed Low visibility due to glare Backup - prior incident Leaving Traffic Lane Manner FOURTH Failed to yield - Emrgcy Veh(s) Low visibility due to smoke Debris Entering Traffic Lane EVENT Failed to yield - Police Veh(s) Other visual obstruction(s) Obstruction in road Over-correcting Failed to yield right-of-way Weather conditions Road defect Parked /Over-steering Following too closely MOTOR VEHICLE Road surface conditions Stopped in Traffic Ran Red Light MHE High speed pursuit Coupling device (hitch, chains) Traffic Congestion Other (Specify in narrative) Improper backing Defective Steering Traffic control not functioning Wrong Way DRIVER/PED/PEDALCYCLIST SOBRIETY DRIVER/PED/PEDALCYCLIST PHYSICAL COND. PEDESTRIAN/PEDALCYCLIST ACTION (Check 1 or more for each) (Mark 1 or more for each) At Intersection Not at Intersection Consumed Alcohol ACTIONS PRIOR TO CRASH LOCATION AT TIME OF CRASH Fatigue- Under the influence of Crossing Roadway Intersection - Marked Crosswalk Consumed a Controlled Substance Moving Against Traffic Intersection - Unmarked Crosswalk Asleep Had Not Consumed Alcohol Medication/Drugs/Alcohol Moving With Traffic Intersection - Other Eyesight Waiting to Cross Roadway Median/Crossing Island Sobriety Unknown Amputee Imp. Walking/Cycling on Sidewalk Midblock - Marked Crosswalk Consumed Medication No App. Defects In Roadway - Other Travel Lane - Other Location Hearing Tested by Instrument for: *Other Adjacent to Roadway (shoulder, median) Bicycle Lane Imp. Physical Working in Trafficway (Incident Response) Shoulder/Roadside Alcohol Drugs Both Illness, Impairment ACTIONS AT TIME OF CRASH Sidewalk Breath Test Administered No Improper Action Driveway Access DRIVER Fainted Emotional Dart/Dash Shared-use Path or Trail gms/210 L gms/210L *Other (depressed, angry, Failure to yield right-of-way Non-trafficway Area Blood Test Administered disturbed, etc.) Failure to Obey Traffic Signs, Signals From behind obstruction Unkown Other (specify in narrative) Standard Field Sobriety Test Administered In roadway improperly (standing, lying, working, playing) Refused Test *Specify in narrative Pushing or working on vehicle PEDESTRIAN/PEDALCYCLIST Entering/Exiting Parked/Standing Vehicle Test not Given Not Visible (dark clothing, no lighting, etc.) Suspected Drug Use Improper Turn/Merge Improper Passing Wrong-way Riding or Walking Seat Sex Injury OP OP Used Airbag Race Ejected Med Trans Occupant’s Name (Last, First, Middle) Occupant’s Address (City, State, ZIP) Pos.
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