STATE OF MISSISSIPPI 01 UNIFORM CRASH …

1 G21. First Harmful EventRear end slow or stopRear end turnLeft turn same roadwayLeft turn cross trafficRight turn cross trafficHead onSideswipeAngleHit and runOverturnJackknifeFell from vehicleOtherPedestrianParked VehicleTrainBicyclistDeerAnimal (other than deer)Bridge/CulvertEmbankment/Ditch/Curb Guardrail/Median BarrierTreeUtility pole/light supportOther fixed objectSign PostSignal standardBuilding/Other StructureMaint. Equip. - Not MovingMaint. Equip. - MovingOther non-fixed objectG5. Officer TimeG23. Intersection TypeNoneFour-way InterT - IntersectionCrossoverDrivewayFive-point or moreOff RampOn RampPath/TrailRR XingTraffic Circle/RoundY - IntersectionAgency NameG1. CountyG18. City NameG11. Hwy/County Road #G17. Int. Hwy/County Road #G13. DirectionNSEWG16.

2 Intersecting Street NameG10. Street NameG9. Address NumberG19. Light ConditionDaylightDark-LitDark-UnlitDawnD uskG28. Workzone RelationshipNot Workzone RelatedWithin Construction ZoneAdvance Warning AreaG29. Workzone Type (2)NoneIntermittent or Moving WorkLane ClosureLane Shift/CrossoverShoulder/Median WorkUtilityG2. Status CodeCPUG46. Badge NumberG49. Reviewing Badge NumberG51. Photos TakenYNWITNESS(ES)WNFMNon- CRASH in RoadCrash of MV in road with: CRASH with OMV in road:Fixed ObjectG6. VehiclesG7. KilledG8. InjuredG50. Reviewing Officer InitialsG22. CRASH LocationRoadwayOff-RoadwayMedianRoadside ShoulderParking LotGoreG24. Roadway SystemCity StreetState HighwayCounty RoadParking Lot/Private DriveInterstateOff RoadState ParkG48. Officer SignatureG47.

3 Investigating Officer Name (Please Print)G52. Photographer and Badge #G36. SexMFG37. AgeG31. AddressG32. Phone NumberG33. CityG35. Zip CodeLast NameMIG30. First NameG34. StateG44. SexMFG45. AgeG39. AddressG40. Phone NumberG41. CityG43. Zip CodeLast NameMIG38. First NameG42. StateG4. Reported Time (2400) STATE OF MISSISSIPPI UNIFORM CRASH REPORTPage01ofG12. Trafficflow DirectionNSEWA rrival Time (2400)10-24 Time (2400)G26. Road ConditionDryWetWaterSand/Mud/Dirt/Oil/Gr avelIceSlushSnowG27. Weather Condition (2)ClearRainCloudyHigh windsBlown DebrisFog/Smog/SmokeSleet/HailSnowAgency NumberAgency Case NumberG3. Reported Date (MM/DD/YYYY)//Non-fixed ObjectAgency NumberAgency Case Number4479140593N2. Collision NarrativeNorthArrowofPage02 MUCRD iagram/NarrativeN1.

4 Collision DiagramAgency NumberAgency Case Number1772140596V25. Bikeway TypeNoneRight onlyLeft OnlyBoth SidesSeparateSignedCargo Loss/ShiftCrossoverEquipment FailureFell/Jump from VehicleFire/ExplosionImmersionJackknifeM edian/CenterlineThrown/Falling ObjectOff roadway/LeftOff roadway/RightOverturn/RolloverUnit SeparationAnimalBicyclistMaintenance VehicleParked VehiclePedestrianTrainAttenuator/Cushion Bridge StructureCulvertCurbDitchEmbankmentFence GuardrailMailboxMedian BarrierPost/Pole/SupportTreeOther Fixed ObjectSlowing VehicleStopped Vehicle in RoadOver Correcting/SteeringV2. StateV3. YearV4. License Plate NumberV10. Speed ZoneV5. MakeV7. Vehicle ModelV6. Model YearV22. Vehicle ConfigurationPassenger CarLight TruckStationwagon/VanSUVM otorcycleOtherRVSchool BusSingle-Unit Truck(2)Single-Unit Truck(3+)Farm TractorTractor/SemiTrailerTractor(2)Trac tor(3)TrainTruck/TrailerEmergency BusATVFarm TruckV9.

5 Damage:HeavyLightNoneC2. AuthorityUS DOTMCS tateMexicoCanadaC8. GVWR #C11. Placard IDC12. HAZMAT ReleasedYesNoC1. Carrier ID Number:V0. Vehicle #:C10. Commodity HauledC3. Carrier NameC4. Carrier AddressC5. CityC6. StateC7. Zip CodeV1. Total OccupantsV21. Vehicle ActionGoing StraightMaking Left TurnStoppedSlow/Stop in RoadParkedBackingMaking Right TurnAvoidanceLane ChangeLeaving ParkingOvertaking/PassingParking PositionMaking U TurnIn TowV31. Center Turn Lane?YesNoV30. Divided?YesNoV26. Traffic Control DeviceChannel-PaintedChannel-PhysicalFla g PersonFlashing Signal RedFlashing Signal YellowNo PassingNoneOfficerRR Flashing SignalRR Signal and GateSignalStop SignRailroad SignYield SignV27. Device Functioning?YNNon-CollisionCollision w/ Person, Vehicle/Non-fixed ObjectCollision w/ Fixed ObjectV13.

6 AddressV14. CityV16. Zip CodeV12. Owner NameV15. StateV17. Insurance Company NameV18. Policy NumberV11. Est. SpeedV8. Vehicle ColorCommercial VehicleV24. Direction of Travel123412341234V20. Sequence of EventsOwner InformationV35. Towed By:V34. Authority:OwnerPoliceOtherV33. Towed?YesNo MUCRV ehicleV32. Road Surface TypeAsphaltConcreteDirtGravelOther - See NarrativeV28. Road CharacterStraight/LevelIntersect two roadsStraight/GradeCurve/LevelStraight/H illcrestCurve/GradeBridgePrivate DriveCurve/HillcrestCrossoverBegin/End Divided RoadOne-WayC9. Cargo Body TypeAuto transporterBus<15 Bus 15+Cargo tankConcrete MixerDumpFlatbedGarbage/refuseGrain/chip s/gravelOtherPole/logVan/enclosed boxNoneAgency NumberAgency Case NumberofPageV23. Initial ContactUnderOverturnNoneOtherV29.

7 Road Design2 Lane4+Parking Lot1 Lane3 LaneFrontage/RampOne WayUnpavedof Insurance V19. No ProofSame asDriver9614432302P0. Person #:V0. Veh. #TypeNoneBloodBreathSerumUrineStatusNone givenTest refusedTest givenTest given, pendingTypeNoneBloodSerumUrineStatusNone givenTest refusedTest given, pendingTest Contributing Circumstance (3)No Apparent Improper DrivingFailed to Yield Right of WayFollowing Too CloselySpeed Too Fast For ConditionsDriving Under The InfluenceAnimal on RoadwayFaulty EquipmentExceeded Lawful SpeedImproper Passing/OvertakingMade Improper TurnLeft of CenterFailure to keep proper lane/Run off roadAvoidanceDrove on Wrong Side of RoadFatigued/AsleepIllegally Crossing MedianImproper Lane ChangeLying and/or illegally in roadwayNot Visible (Dark Clothing)Operating Defective EquipmentPassed Stop SignPedestrian ActionsRan Red LightRoadway DefectsVisibility ObstructedImproper BackingSee CRASH DescriptionSafety Equip.

8 (2)Shoulder & Lap BeltNoneLap BeltAutomated RestraintShoulder BeltChild Safety SeatHelmetAirbagDeployed - FrontDeployed - SideDeployed - BothNot DeployedNo Airbag1212P19. ConditionNo Defects ApparentUnknownHit and RunDrinking - Not impairedDrinking - ImpairedFell Asleep/Fainted/FatigueObviously IntoxicatedPhysical ImpairmentAffected by Exhaust FumesUsing Drugs - ImpairedUsing Drugs - Not ImpairedPending Lab ResultsP7. AddressP8. Phone NumberP9. CityP11. Zip CodeP13. CitedYNPP10. StateP16. XportNot TransportedEMSP olicePrivate VehicleHearseP6. First NameMILast NameSexMFRaceWhiteBlackHispanicOtherPosi tionLeftCenterRightExtricatedNYP2. License #P3. STATE P4. CDL?NYP23. Injury TypeNoneComplaint of PainSeriousLife ThreateningKilledPageofP1. Person TypeDriverPedestrianBicyclistSkaterOther non-motoristTrain EngineerHit and Run DriverAlcohol Test Information MUCRP erson/OccupantDrug Test InformationP14.

9 Ticket #P12. DL StatusValidNo LicenseExpiredSuspendedSuspended - DUIL earner PermitImproper DLOtherP15. OffenseP20. Non-Motorist ActionUnknownEntering/Crossing RoadwayWalking/running/playing/cyclingWo rkingPushing vehicleApproaching/leaving vehiclePlaying/working on vehicleStandingAgency NumberAgency Case NumberP17. EMSA gency CodeP18. MedicalFacility CodeP24. EjectionNotPartiallyTotallyP5. DOB (MM/DD/YYYY)//O9. RaceWhiteBlackHispanicOtherO10. AgeO11. ExtricatedNYO12. EjectionNotPartiallyTotallyO13. Injury TypeNoneComplaint of PainSeriousLife ThreateningKilledO6. PositionFront-DriverFront-MiddleFront-ri ght2nd-left2nd-middle2nd-right3rd-left3r d-middle3rd-rightSleeper of Truck CabEncl. AreaUnencl. AreaRiding on ExteriorTowed Safety Equip. (2)Shoulder and Lap BeltNoneLap BeltAutomated RestraintShoulder BeltChild Safety SeatHelmetO14.

10 AirbagDeployed - FrontDeployed - SideDeployed - BothNot DeployedNo AirbagO15. XportNot TransportedEMSP olicePrivate VehicleHearseO0. Vehicle #:Facility CodeAgency CodeO3. AddressO5. StateO4. CityO16. EMSO17. MedicalMYLast NameMIO1. First NameO2. AddressSame asPerson #OccupantO8. SexMFUnborn ChildO9. RaceWhiteBlackHispanicOtherO10. AgeO11. ExtricatedNYO12. EjectionNotPartiallyTotallyO13. Injury TypeNoneComplaint of PainSeriousLife ThreateningKilledO6. PositionFront-DriverFront-MiddleFront-ri ght2nd-left2nd-middle2nd-right3rd-left3r d-middle3rd-rightSleeper of Truck CabEncl. AreaUnencl. AreaRiding on ExteriorTowed Safety Equip. (2)Shoulder and Lap BeltNoneLap BeltAutomated RestraintShoulder BeltChild Safety SeatHelmetO14. AirbagDeployed - FrontDeployed - SideDeployed - BothNot DeployedNo AirbagO15.