Police Accident Report MV-104COV - New York DMV

1 PEDESTRIAN/BICYCLIST/OTHER PEDESTRIAN LOCATION APPARENT CONTRIBUTING. APPARENT CONTRIBUTING FACTORS FACTORS. 1. Pedestrian/Bicyclist/Other Pedestrian at Intersection HumanHumanHumanHuman HumanHuman HumanHuman Human HumanHuman Human Human Vehicular 2. Pedestrian/Bicyclist/Other Pedestrian Not at Intersection 2. Alcohol InvolvementAlcohol InvolvementAlcohol Involvement Involvement Involvement Vehicle 19. Vehicular 41. Accelerator Defective 1. PEDESTRIAN/BICYCLIST/ 3. Backing UnsafelyBacking UnsafelyBacking Unsafely Unsafely Unsafely 42. Brakes Defective OTHER PEDESTRIAN ACTION 4. Driver Inattention/Distraction*Driver Inattention/Distraction*Driver Inattention/Distraction*. Inattention/Distraction* Inattention/Distraction*. 43. Headlights Defective 1 1.

2 Crossing, With Signal 8. Going to/From Stopped 5. Driver Inexperience*Driver Inexperience*Driver Inexperience*. Inexperience* Inexperience* 44. Other Lighting Defects 2. Crossing, Against Signal School Bus 6. Drugs (Illegal)Drugs (Illegal)Drugs (Illegal). (Illegal) (Illegal) 45. Oversized Vehicle 3. Crossing, No Signal, Marked 9. Getting On/Off Vehicle 7. Failure toto Yield Yield Right-of-WayFailure Right-of-WayFailure to Right-of-Way Yield to 46. Right-of-Way YieldSteering Right-of-Way Failure Vehicle 20. Crosswalk Other Than School Bus 8. Fell AsleepFell AsleepFell Asleep Asleep Asleep 47. Tire Failure/Inadequate 1. 4. Crossing, No Signal or 11. Working in Roadway 9. Following Too Too CloselyFollowing CloselyFollowing Too Closely Too Closely Closely 48.

3 Tow Hitch Defective Crosswalk 12. Playing in Roadway 10. IllnessIllness Illness 49. Windshield Inadequate 5. Riding/Walking/Skating Along 13. Other Actions in Roadway* 11. Lost ConsciousnessLost ConsciousnessLost Consciousness Consciousness Consciousness 50. Driverless/Runaway Vehicle Highway With traffic 14. Not in Roadway (Indicate)* Passenger 12. Passenger DistractionPassenger DistractionPassenger Distraction Distraction Distraction 51. Tinted Windows 2 6. Riding/Walking/Skating Along 13. Passing or or Lane Lane Usage Usage ImproperPassing ImproperPassing Improper or or Lane 60. Lane Usage Usage Improper Improper Highway Against traffic 14. Pedestrian/Bicyclist/Other Other Vehicular* Vehicle 21. 7. Emerging from in Front of/ Environmental 2.

4 Pedestrian Pedestrian Error/. Error/. Error/Confusion 61. Animal's Action Behind Parked Vehicle 15. Physical ConfusionPedestrian DisabilityPhysical ConfusionPedestrian DisabilityPhysical Disability Error/. Error/Disability Disability 62. 16. Prescription MedicationPrescription Confusion Confusion MedicationPrescription Medication Medication Glare Medication traffic CONTROL 63. Lane Marking Improper/. 1. None 8. RR Crossing Sign 13. Maintenance traffic 17. traffic Control Control DisregardedTraffic DisregardedTraffic Control Disregarded Control Disregarded Disregarded Inadequate 2. traffic Signal 9. RR Crossing Work Area 18. Turning ImproperlyTurning ImproperlyTurning Improperly Improperly Improperly 64. Obstruction/Debris Vehicle 22. 3. Stop Sign Flashing Light 14.

5 Utility Work Area 19. Unsafe SpeedUnsafe SpeedUnsafe Speed Speed Speed 65. Pavement Defective 2. 4. Flashing Light 10. RR Crossing Gates 15. Police /Fire 20. Unsafe Lane Lane ChangingUnsafe ChangingUnsafe Changing Lane Lane Changing Changing 66. Pavement Slippery 5. Yield Sign 11. Stopped School Bus- Emergency 21. Fatigued/DrowsyFatigued/Drowsy Fatigued/Drowsy 67. Shoulders Defective/. 3 6. Officer/Guard Red Lights Flashing 16. School Zone 22. Cell Phone Phone (hand-held)Cell (hand-held)Cell Phone (hand-held) Phone (hand-held). (hand-held). Improper 7. No Passing 12. Construction 20. Other* Cell 23. Cell Phone Phone (hands-free)Cell (hands-free)Cell Phone (hands-free) Phone (hands-free). (hands-free). 68. traffic TrafficControl ControlDevice Device Zone Work Area 24.

6 Other Electronic Electronic Device*Other Device*Other Electronic Device* Electronic Device*. Device*. Improper/Non-Working Improper/Non-Working 25. Outside Car Car Distraction*Outside Distraction*Outside Car Distraction* Car Distraction*. Distraction*. 69. View Obstructed/Limited LIGHT CONDITIONS New york State 26. Reaction to to Uninvolved Uninvolved VehicleReaction VehicleReaction to Vehicle to Uninvolved Uninvolved Vehicle Vehicle 1. Daylight DIRECTION. DIRECTION N. 2. Dawn Department of Motor Vehicles 27. Failure toto Keep Keep RightFailure RightFailure to Right to Keep Keep OF. Right Right N Vehicle 23. 4 Aggressive 28. Aggressive Driving/Road Driving/Road Rage*Aggressive Rage*Aggressive Rage* NW. Driving/Road Driving/Road Rage* E. Rage* 1.

7 3. Dusk 4. Dark-Road Lighted Police Accident Report 29. Passing Too Too CloselyPassing CloselyPassing Too Closely TRAVEL: TRAVEL: Too Closely Closely 1 2. Vehicle 30. Vehicle VandalismVehicle VandalismVehicle Vandalism Vandalism Vandalism 8. 5. Dark-Road Unlighted MV-104 COV(11/13). MV-104 COV (7/18) 31. TextingTexting Texting W 7 3 E. ROADWAY CHARACTER *EXPLAIN IN Accident DESCRIPTION Using 32. Using On On Board Board Navigation Navigation DeviceUsing DeviceUsing Device On On Board 6 5 4 Device Board Navigation Navigation Device 33. Eating or or DrinkingEating DrinkingEating or Drinking or Drinking Drinking SW Vehicle 24. 1. Straight and Level If a question DOES NOT APPLY, 2. SE. 2. Straight and Grade 34. Listening/Using HeadphonesListening/Using HeadphonesListening/Using Headphones Headphones Headphones S.

8 5 3. Straight at Hillcrest enter a dash (( ). ). 4. Curve and Level PRE- Accident VEHICLE. PRE- Accident VEHICLE ACTION ACTION. 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. 1. Dry 3. Muddy 5. Slush SEVERE PHYSICAL 17. Making Left Turn on Red 20. Other *. 6 2. Wet 4. Snow/Ice 6. Flooded COMPLAINT 4. Making U Turn 0. Other* 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 2. Cloudy 6. Fog/Smog/Smoke 4.

9 Neck 9. Entering Parked Position Vehicle 26. 3. Rain 0. Other* 5. Chest 10. Parked 2. 7 6. Back/Spine 11. Avoiding Object in Roadway 4. Snow 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 Roadway 1. Vehicle No. 1 A. All-Terrain Vehicle (ATV) * 11. Knee-Lower Leg-Foot TYPE. TYPE TYPE OF OF. OF Accident . Accident . Accident -- COLLISION. -- COLLISION. -- COLLISION WITH. WITH. WITH. 2. Vehicle No. 2 B. Bicyclist P. Pedestrian 12. Entire Body I. In-Line Skater S. Snowmobiler 1. 1. Other Motor 1. Other Other Motor Motor Vehicle Vehicle7. Vehicle Deer Deer 2. 2. Pedestrian 2. Pedestrian Pedestrian 8. Otherpedestrian Other pedestrian pedestrian POSITION IN/ON VEHICLE 3.

10 3. Bicyclist 3. Bicyclist Bicyclist 10. 10. OtherObject Other Object Object 1. Driver 2-7. Passengers TYPE OF PHYSICAL COMPLAINT 4. 4. Animal 4. Animal Animal (Not (Not (Not Fixed)**. Fixed). Fixed). 8. Riding/Hanging on Outside Amputation Amputation 14. Whiplash 5. Railroad 5. Railroad Train 5. RailroadTrain Train Concussion Concussion 15. Crush Injuries SAFETY EQUIPMENT USED Internal Internal 16. Paralysis COLLISION. COLLISION. COLLISION WITH. WITHWITHFIXED. FIXEDFIXEDOBJECT. OBJECT. OBJECT. 1. None Minor MinorBleeding Bleeding 17. Severe Lacerations 11. Light 11. 11. Light Support/Utility Support/Utility Light Support/UtilityPole Pole Pole First 2. Lap Belt 28. Severe SevereBleeding Bleeding 12. Guide 12. 12. Guide Rail-Not Rail-Not Guide At At End Rail-Not End At End Event 3.