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Submission of Crash Records: This report may be …

TEXAS PEACE OFFICER S Crash report CRB-3 (Rev. 01/06) Submission of Crash Records: This report may be submitted via the CRIS Web Portal, electronically submitted via XMLor mailed to the TEXAS departmentof PUBLIC SAFETY, PO BOX 4087, AUSTIN TX 78773-0350. Please see the DPS Instructions to Police for more details regarding these Submission methods or look on the CRIS Website at INVOLVEDSCHOOL BUS RELATEDRAILROAD RELATEDMEDICAL ADVISORY BOARDHIT AND RUNAMENDMENT/ SUPPLEMENTPLACE WHERE Crash OCCURREDCOUNTY CITY OR TOWN IF Crash WAS OUTSIDE CITY LIMITSINDICATE FROM NEAREST TOWN MILESN SE W OF LOC # ORI # DPS # ROAD ON WHICHCRASH OCCURRED BLOCK NUMBERSTREET OR ROAD NAMEROUTE NUMBER OR STREET CODEINTERSECTING STREETOR RR X ING NUMBER BLOCK NUMBERSTREET OR ROAD NAMEROUTE NUMBER OR STREET CODENOT AT INTERSECTION CONSTRUCTION ZONEYESNOSPEED WORKERS PRESENTYESNOLIMIT CONSTRUCTION ZONEYESNOSPEED WORKERS PRESENTYESNOLIMIT LATITUDE LONGITUDE N S E WOF SHOW MILEPOST OR NEAREST INTERSECTING

TEXAS PEACE OFFICER’S CRASH REPORT CRB-3 (Rev. 01/06) Submission of Crash Records: This report may be submitted via the CRIS Web Portal, electronically submitted via XMLor mailed to the TEXAS DEPARTMENTOF

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Transcription of Submission of Crash Records: This report may be …

1 TEXAS PEACE OFFICER S Crash report CRB-3 (Rev. 01/06) Submission of Crash Records: This report may be submitted via the CRIS Web Portal, electronically submitted via XMLor mailed to the TEXAS departmentof PUBLIC SAFETY, PO BOX 4087, AUSTIN TX 78773-0350. Please see the DPS Instructions to Police for more details regarding these Submission methods or look on the CRIS Website at INVOLVEDSCHOOL BUS RELATEDRAILROAD RELATEDMEDICAL ADVISORY BOARDHIT AND RUNAMENDMENT/ SUPPLEMENTPLACE WHERE Crash OCCURREDCOUNTY CITY OR TOWN IF Crash WAS OUTSIDE CITY LIMITSINDICATE FROM NEAREST TOWN MILESN SE W OF LOC # ORI # DPS # ROAD ON WHICHCRASH OCCURRED BLOCK NUMBERSTREET OR ROAD NAMEROUTE NUMBER OR STREET CODEINTERSECTING STREETOR RR X ING NUMBER BLOCK NUMBERSTREET OR ROAD NAMEROUTE NUMBER OR STREET CODENOT AT INTERSECTION CONSTRUCTION ZONEYESNOSPEED WORKERS PRESENTYESNOLIMIT CONSTRUCTION ZONEYESNOSPEED WORKERS PRESENTYESNOLIMIT LATITUDE LONGITUDE N S E WOF SHOW MILEPOST OR NEAREST INTERSECTING

2 NUMBERED HIGHWAY, IF NONE, SHOW NEAREST INTERSECTING STREET OR REFERENCE POINTMILEPOSTDATE OFDAY OFAM IF EXACTLY NOONCRASH WEEK HOUR PM OR MIDNIGHT, SO STATEMONTHDATE YEAR1-MOTOR VEHICLE 4-PEDESTRIAN7-NON-CONTACTALTEREDYES2-TRA IN5-MOTORIZED CONVEYANCE 8-OTHERVIN# VEHICLE HEIGHT NO3-PEDALCYCLIST6-TOWEDYEAR COLOR &MODELBODYLICENSEMODEL MAKE NAME STYLE PLATE YEAR STATE NUMBERDRIVER SPHONE NAME NUMBER LASTFIRSTMIDDLEADDRESS (STREET, CITY, STATE, ZIP)DRIVER SLICENSELICENSE STATUSSTATENUMBERCLASS/TYPEENDORSEMENTSR ESTRICTIONSDATE OF BIRTHDRIVER SDRIVER SMALE DRIVER SETHNICITYSEX FEMALE OCCUPATION POLICE, FIREFIGHTER, EMS, ON EMERGENCY TYPE OF ALCOHOLSPECIMEN TAKENTESTTYPE OF DRUG SPECIMEN TAKENTESTDRUG1-BREATH 2-BLOOD 3-URINE 4-NONE 5-REFUSEDRESULTS 1-BLOOD 2-URINE 3-NONE 4-REFUSED RESULTS CATEGORYLESSEEOWNER NAME (ALWAYS SHOW LESSEE IF LEASED, OTHERWISE SHOW OWNER) ADDRESS (STREET, CITY, STATE, ZIP)

3 LIABILITY YESINSURANCE NO VEHICLE DAMAGE RATING EXP INSURANCE COMPANY NAME POLICY NUMBERUNIT #1-VALID4-CANCELLED/DENIED2-NOT VALID5-EXPIRED3-SUSPENDED/REVOKED 6-UNKNOWN1-WHITE 4-ASIAN2-HISPANIC 5-OTHER3-BLACKIF CHECKED, PLEASE EXPLAIN IN NARRATIVE1. 2. DAMAGE TO PROPERTY OTHER THAN VEHICLES$OBJECT NAME AND ADDRESS OF OWNERFEET FROM CURB DAMAGE ESTIMATEIN YOUR OPINION, DID THIS Crash RESULT IN AT LEAST $1, DAMAGE TO ANY ONE PERSON S PROPERTY? YES NOCHARGES FILEDNAME CHARGE CITATION# NAME CHARGE CITATION# TIME NOTIFIEDTIME ARRIVEDDATE OFOF Crash HOW AT SCENE REPORTDATEHOURDATEHOURTYPED OR PRINTEDREPORTYES NAME OF INVESTIGATOR ID# AGENCY DIST/AREA COMPLETE NO1-MOTOR VEHICLE 4-PEDESTRIAN7-NON-CONTACTALTEREDYES2-TRA IN5-MOTORIZED CONVEYANCE 8-OTHERVIN# VEHICLE HEIGHT NO3-PEDALCYCLIST6-TOWEDYEAR COLOR &MODELBODYLICENSEMODEL MAKE NAME STYLE PLATE YEAR STATE NUMBERDRIVER SPHONE NAME NUMBER LASTFIRSTMIDDLEADDRESS (STREET, CITY, STATE, ZIP)

4 DRIVER SLICENSELICENSE STATUSSTATENUMBERCLASS/TYPEENDORSEMENTSR ESTRICTIONSDATE OF BIRTHDRIVER SDRIVER SMALE DRIVER SETHNICITYSEX FEMALE OCCUPATION POLICE, FIREFIGHTER, EMS, ON EMERGENCY TYPE OF ALCOHOLSPECIMEN TAKENTESTTYPE OF DRUG SPECIMEN TAKENTESTDRUG1-BREATH 2-BLOOD 3-URINE 4-NONE 5-REFUSEDRESULTS 1-BLOOD 2-URINE 3-NONE 4-REFUSED RESULTS CATEGORYLESSEEOWNER NAME (ALWAYS SHOW LESSEE IF LEASED, OTHERWISE SHOW OWNER) ADDRESS (STREET, CITY, STATE, ZIP)LIABILITY YESINSURANCE NO VEHICLE DAMAGE RATING EXP INSURANCE COMPANY NAME POLICY NUMBERUNIT #1-VALID4-CANCELLED/DENIED2-NOT VALID5-EXPIRED3-SUSPENDED/REVOKED 6-UNKNOWN1-WHITE 4-ASIAN2-HISPANIC 5-OTHER3-BLACKIF CHECKED, PLEASE EXPLAIN IN NARRATIVE1.

5 2. SEAT POSITION1-FRONT LEFT7-THIRD SEAT LEFT2-FRONT CENTER8-THIRD SEAT CENTER3-FRONT RIGHT9-THIRD SEAT RIGHT4-SECOND SEAT LEFT10-CARGO AREA5-SECOND SEAT CENTER11-OUTSIDE VEHICLE6-SECOND SEAT RIGHT12-UNKNOWNSOLICITATIONINDICATES A PERSON S DESIRE TO RECEIVE CONTACT FROM PERSONSSEEKING PROFESSIONAL EMPLOYMENT AS/FOR ATTORNEY,CHIROPRACTOR, PHYSICIAN, SURGEON, PRIVATE INVESTIGATOR, OR ANYOTHER PERSON REGISTERED OR LICENSED BY A HEALTH CARE REGULA-TORY AGENCY (Y=SOLICIT, N=NO SOLICIT).EJECTED1-NO2-YES3-YES, PARTIAL4-NOT APPLICABLE5-UNKNOWNRESTRAINT USED1-SHOULDER & LAP BELT7-BOOSTER SEAT2-SHOULDER BELT ONLY8-NONE3-LAP BELT ONLY9-OTHER4-CHILD SEAT, FACING FORWARD 10-UNKNOWN5-CHILD SEAT, FACING REAR6-CHILD SEAT, UNKAIRBAG1-NOT APPLICABLE2-NOT DEPLOYED3-DEPLOYED, FRONT4-DEPLOYED, SIDE5-DEPLOYED, OTHER6-UNKNOWNHELMET USE1-WORN, DAMAGED2-WORN, NOT DAMAGED3-WORN, UNK.

6 DAMAGE4-NOT WORN5-UNKNOWN IF WORNINJURY SEVERITYK-KILLEDA-INCAPACITATING INJURYB-NON INCAPACITATING INJURYC-POSSIBLE INJURYN-NOT INJUREDU-UNKNOWNITEM#12345 SEATPOSITIONSOLEJECTEDRESTRAINTAIRBAGHEL METAGESEXINJURYUSEDCODECOMPLETE ALL DATA ON ALL OCCUPANTS NAMES, POSITIONS, RESTRAINTS USED, , IT IS NOT NECESSARY TO SHOW ADDRESSES UNLESS KILLED OR INJUREDNAME (LAST, FIRST, MI)ADDRESSTOWED DUE TOYESDISABLING DAMAGENOVEHICLE REMOVED TO BY UNIT#ITEM#678910 SEATPOSITIONSOLEJECTEDRESTRAINTAIRBAGHEL METAGESEXINJURYUSEDCODECOMPLETE ALL DATA ON ALL OCCUPANTS NAMES, POSITIONS, RESTRAINTS USED, , IT IS NOT NECESSARY TO SHOW ADDRESSES UNLESS KILLED OR INJUREDNAME (LAST, FIRST, MI)ADDRESSUNIT#PED., PEDAL.,MOT. CONVEY, IF CASUALTIES NOT IN MOTOR VEHICLECASUALTY NAME (LAST, FIRST, MI)ADDRESSALCOHOLDRUGSOLSPECIMENRESULTSP ECIMENRESULTHELMETAGESEXINJURYTAKENTAKEN CODEDISPOSITION OF KILLED OR INJUREDIF AMBULANCE USED, SHOWITEM#TAKEN TOBYTIMETIME ARRIVEDAMBULANCE# OF ATTENDANTSNOTIFIEDAT SCENEUNIT#INCLUDING DRIVER# OF PERSONSTRANSPORTED FORTREATMENTCOMPLETE THIS SECTION IF PERSON KILLED (If a person dies within 30 days of the Crash , please complete this area and mail the supplement to the Crash Records Bureau)

7 ITEM #DATE OF DEATHTIME OF DEATHITEM#DATE OF DEATHTIME OF DEATH ITEM#DATE OF DEATHTIME OF DEATHITEM#DATE OF DEATHTIME OF DEATHTRAFFIC CONTROL1-NONE7-FLASHING YELLOW LIGHT13-RR GATES/SIGNAL2-INOPERATIVE8-STOP SIGN14-SCHOOL ZONE3-OFFICER9-YIELD SIGN15-CROSSWALK4-FLAGMAN10-WARNING SIGN16-BIKE LANE5-SIGNAL LIGHT11-CENTER STRIPE/DIVIDER17-OTHER6-FLASHING RED LIGHT12-NO PASSING ZONEROADWAY RELATION1-ON ROADWAY2-OFF ROADWAY3-SHOULDER4-MEDIANPART OF THE ROADWAY1-MAIN LANE2-SERVICE ROAD3-ENTRANCE RAMP4-EXIT RAMP5-CONNECTOR6-DETOUR7-OTHERROADWAY ALIGNMENT1-STRAIGHT,LEVEL7-OTHER2-STRAIG HT, GRADE8-UNKNOWN3-STRAIGHT, HILLCREST4-CURVE, LEVEL5-CURVE, GRADE6-CURVE, HILLCRESTLIGHT CONDITION1-DAYLIGHT8-OTHER2-DARK, NOT LIGHTED9-UNKNOWN3-DARK, LIGHTED4-DARK, UNK LIGHTING5-DAWN6-DUSKTYPE OF ROAD SURFACE1-CONCRETE5-DIRT2-BLACKTOP6-OTHER 3-BRICK7-UNKNOWN4-GRAVELWEATHER1-CLEAR/C LOUDY7-SEVERE CROSSWINDS2-RAIN8-OTHER3-SLEET/HAIL9-UNK NOWN4-SNOW5-FOG6-BLOWING SAND/SNOWSURFACE CONDITION1-DRY7-SAND, MUD, DIRT2-WET8-OTHER3-STANDING WATER9-UNK4-SNOW5-SLUSH6-ICE1-TWO-WAY, NOT DIVIDED2-TWO-WAY, DIVIDED, UNPROTECTED MEDIAN3-TWO-WAY, DIVIDED, PROTECTED BARRIER4-ONE-WAY9-UNKNOWNDIAGRAMINDICATE NORTH1-ANIMAL ON ROAD-DOMESTIC40-FATIGUED OR ASLEEP71-WRONG WAY-ONE WAY ROAD2-ANIMAL ON ROAD-WILD41-FAULTY EVASIVE ACTION72-CELL/MOBILE PHONE USE3-BACKED WITHOUT SAFETY42-FIRE IN VEHICLE73-ROAD RAGE4-CHANGED LANE WHEN UNSAFE43-FLEEING OR EVADING POLICE74-OTHER FACTOR (WRITE ON LINE)

8 5-13 SEE VEHICLE DEFECTS44-FOLLOWED TOO CLOSELY14-DISABLED IN TRAFFIC LANE45-HAD BEEN DRINKING15-DISREGARD STOP AND GO SIGNAL46-HANDICAPPED DRIVER (EXP. IN NARRATIVE)16-DISREGARD STOP SIGN OR LIGHT47-ILL (EXP. IN NARRATIVE)17-DISREGARD TURN MARKS AT INTERSECTION48-IMPAIRED VISIBILITY (EXP. IN NARRATIVE)18-DISREGARD WARNING SIGN AT CONSTRUCTION49-IMPROPER START FROM PARKED POSITION19-DISTRACTION IN VEHICLE50-LOAD NOT SECURED20-DRIVER INATTENTION51-OPENED DOOR TO TRAFFIC LANE21-DROVE WITHOUT HEADLIGHTS52-OVERSIZE VEHICLE OR LOAD22-FAILED TO CONTROL SPEED53-OVERTAKE AND PASS INSUFFICIENT CLEARANCE23-FAILED TO DRIVE IN SINGLE LANE54-PARKED AND FAILED TO SET BRAKES24-FAILED TO GIVE HALF OF ROADWAY55-PARKED IN TRAFFIC LANE25-FAILED TO HEED WARNING SIGN56-PARKED WITHOUT LIGHTS26-FAILED TO PASS TO LEFT SAFELY57-PASSED IN NO PASSING ZONE27-FAILED TO PASS TO RIGHT SAFELY58-PASSED ON RIGHT SHOULDER28-FAILED TO GIVE SIGNAL OR WRONG SIGNAL59-PED/ ROW TO VEHICLE29-FAILED TO STOP AT PROPER PLACE60-SPEEDING UNSAFE (UNDER LIMIT)

9 30-FAILED TO STOP FOR SCHOOL BUS61-SPEEDING OVER LIMIT31-FAILED TO STOP FOR TRAIN62-TAKING MEDICATION (EXP. IN NARRATIVE)32-FAILED TO YIELD ROW-EMERGENCY VEHICLE63-TURNED IMPROPERLY - CUT CORNER ON LEFT33-FAILED TO YIELD ROW-OPEN INTERSECTION64-TURNED IMPROPERLY - WIDE RIGHT34-FAILED TO YIELD ROW-PRIVATE DRIVE65-TURNED IMPROPERLY - WRONG LANE35-FAILED TO YIELD ROW-STOP SIGN66-TURNED WHEN UNSAFE 36-FAILED TO YIELD ROW-TO PEDESTRIAN67-UNDER INFLUENCE - ALCOHOL37-FAILED TO YIELD ROW-TURNING LEFT68-UNDER INFLUENCE - DRUG38-FAILED TO YIELD ROW-TURN ON RED69-WRONG SIDE - APPROACH OR IN INTERSECTION39-FAILED TO YIELD ROW-YIELD SIGN70-WRONG SIDE- NOT PASSINGVEHICLE DEFECTS5-DEFECTIVE OR NO HEADLAMPS6-DEFECTIVE OR NO STOP LAMPS7-DEFECTIVE OR NO TAIL LAMPS8-DEFECTIVE OR NO TURN SIG.

10 LAMPS9-DEFECTIVE OR NO TRAILER BRAKES10-DEFECTIVE OR NO VEHICLE BRAKES11-DEFECTIVE OR NO STEERING OR SLICK TIRES13-DEFECTIVE TRAILER HITCHUNIT#FACTORS/CONDITIONS CONTRIBUTINGOTHER FACTORS/CONDITIONS MAY ORVEHICLE DEFECTSVEHICLE DEFECTS MAYMAY NOT HAVE CONTRIBUTEDCONTRIBUTINGHAVE CONTRIBUTED12312312121231231212 FACTORS AND CONDITIONS LISTED ARE THE INVESTIGATOR S OPINIONTOWED DUE TOYESDISABLING DAMAGENOVEHICLE REMOVED TO BY INVESTIGATOR S NARRATIVE OPINION OF WHAT HAPPENED (ATTACH ADDITIONAL SHEETS IF NECESSARY)24. TOTAL NUMBER OF AXLES25. TOTAL NUMBER OF TIRESTRAILER NUMBER 2 INFORMATION21. LICENSE PLATE22. GROSS VEHICLE WEIGHT RATING (GVWR)cREGISTERED GROSS VEHICLE WEIGHT (RGVW)cTRAILER NUMBER 1 INFORMATION19. LICENSE PLATE20. GROSS VEHICLE WEIGHT RATING (GVWR)cREGISTERED GROSS VEHICLE WEIGHT (RGVW)cTRAILER TYPE1-FULL TRAILER2-SEMI TRAILER3-POLE TRAILERCRB-3C (Rev.)


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