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TraCS KEY NO. <br />Investigator’s Motor Vehicle Crash Report - All Drivers & Occupants <br />Sheetof <br />66 <br />L <br />PERSON TYPESEATING POSITIONRESTRAINT SYSTEM / HELMET USEINJURY <br />P4. RowP8. Restraint SystemP12. Injury Status <br />P1. Incident Responder? <br />01 - Front01 - Booster Seat00 - No Apparent Injury <br />01 - Yes <br />02 - Second02 - Child Restraint System - Forward Facing01 - Fatal Injury \[must complete Fatal Crash Report <br />02 - No <br />03 - Third03 - Child Restraint System - Rear Facing NDOT Form 179\] <br />04 - Fourth04 - Child Restraint System - Type Unknown02 - Suspected Serious Injury* <br />P2. If yes, type of Incident Responder <br />05 - Other Row (bus,05 - Lap Belt Only Used03 - Suspected Minor Injury <br />01 - EMS <br /> 15-passenger van, etc.)06 - None Used - Motor Vehicle Occupant04 - Possible Injury <br />02 - Fire <br />99 - Unknown07 - Restraint Used - Type Unknown99 - Unknown <br />03 - Police <br />08 - Shoulder & Lap Belt Used <br />* Suspected Serious Injury: Any injury, other than <br />04 - Tow Operator <br />09 - Shoulder Belt Only Used <br />P5. Seat <br />05 - Transportation (maintenance workers, fatal, which results in one or more of the <br />10 - Stretcher <br />01 - Left <br /> following: Severe laceration resulting in exposure <br /> safety service operators, etc.) <br />11 - Wheelchair <br />02 - Middle <br />98 - Other of underlying tissues, muscle, organs, or <br />Motorcycle Helmet Use <br />03 - Right <br /> resulting in significant loss of blood, broken or <br />99 - Unknown <br />12 - DOT-Compliant Motorcycle Helmet <br />98 - Other <br /> distorted extremity (arm or leg), crush injuries, <br />13 - Non DOT-Compliant Motorcycle Helmet <br />Does the crash involve a Non-Motorist? <br />99 - Unknown <br /> suspected skull, chest, or abdominal injury other <br />14 - Unknown If DOT-Compliant Motorcycle Helmet <br />01 - Yes – Complete Non-Motorist Report <br /> than bruises or minor lacerations, significant <br />15 - No Helmet <br /> NDOT Form 178 for the followingP6. Other Location burns (second and third degree burns over 10% <br />97 - Not Applicable <br /> person types: <br /> or more of the body), unconsciousness when <br />01 - Enclosed Cargo Area <br />98 - Other <br /> - Bicyclist taken from the crash scene, or paralysis. <br />02 - Riding on Motor Vehicle <br />99 - Unknown <br /> - Other Cyclist <br /> Exterior (non-trailing unit) <br />P13. Injury Area <br /> - Pedestrian <br />03 - Sleeper Section of Cab <br />P9. Any Indication of Improper Restraint Use? <br />00 - None <br /> - Other Pedestrian (wheelchair, <br /> (truck) <br />01 - Yes <br />01 - Abdomen & Pelvis <br /> skater, person in a building, <br />04 - Trailing Unit <br />02 - No <br />02 - Entire Body <br /> parked vehicle, or a personal <br />05 - Unenclosed Cargo Area <br />99 - Unknown <br />03 - Face <br /> conveyance, etc.) <br />97 - Not Applicable <br />04 - Head <br /> - Occupant of a Non-Motor Vehicle <br />98 - Other <br />P10. Air Bag Deployed(up to 4 choices) <br />05 - Lower Extremity (legs) <br /> Transportation Device <br />99 - Unknown <br />00 - Not Deployed <br />06 - Neck <br /> - Unknown Type of Non-Motorist** <br />02 - Curtain <br />07 - Spine <br />P7. Ejection <br />03 - Front <br />08 - Chest (thorax) <br />02 - No – Continue to P3 below. <br />01 - Not Ejected <br />04 - Side <br />09 - Upper Extremity (arms) <br />02 - Ejected, Partially <br />97 - Not Applicable <br />10 - Unspecified <br />P3. Occupant of Motor Vehicle <br />03 - Ejected, Totally <br />98 - Other (knee, air belt, etc.) <br />99 - Unknown <br />01 - Driver <br />97 - Not Applicable <br />99 - Unknown <br />02 - Occupant <br />99 - Unknown <br />P14. Source of Transport to <br />P11. School Bus Restraint Availability <br />03 - Occupant of MV Not in Transport <br /> First Medical Facility <br />(excludes driver) <br />00 - Not Transported <br />00 - No Restraint Available <br />01 - EMS Air <br />01 - Lap Belt Available & Not Used <br />02 - EMS Ground <br />02 - Shoulder & Lap Available & Not Used <br />03 - Law Enforcement <br />97 - Not Applicable <br />98 - Other <br />99 - Unknown <br />99 - Unknown <br />All Drivers & Occupants <br />Vehicle No.Occupant No.NAME OF PERSON INVOLVED (Last, First, Middle) <br />SEX <br />02 <br />11 JONES, CHANDRA, S <br />01 - Male 02 - Female 99 - Unk. <br />CITY, STATE, ZIP <br />ADDRESSDATE OF BIRTH (MMDDYYYY)DOB Unk. <br />04/22/1993 <br />203 E PINE STREETALDA, NE, 68810 <br />Person TypeSeating PositionRestraint System / Helmet UseInjury <br />P1P2P3P4P5P6P7P8P9P10P11P12P13P14 <br />2010101970108020097000000 <br />MEDICAL FACILITY NAMEEMS SERVICE NAMEEMS RUN NO. <br />Vehicle No.Occupant No.NAME OF PERSON INVOLVED (Last, First, Middle) <br />SEX <br />01 - Male 02 - Female 99 - Unk. <br />CITY, STATE, ZIP <br />ADDRESSDATE OF BIRTH (MMDDYYYY)DOB Unk. <br />Person TypeSeating PositionRestraint System / Helmet UseInjury <br />P1P2P3P4P5P6P7P8P9P10P11P12P13P14 <br />MEDICAL FACILITY NAMEEMS SERVICE NAMEEMS RUN NO. <br />Vehicle No.Occupant No.NAME OF PERSON INVOLVED (Last, First, Middle) <br />SEX <br />01 - Male 02 - Female 99 - Unk. <br />CITY, STATE, ZIP <br />ADDRESSDATE OF BIRTH (MMDDYYYY)DOB Unk. <br />Person TypeSeating PositionRestraint System / Helmet UseInjury <br />P1P2P3P4P5P6P7P8P9P10P11P12P13P14 <br />MEDICAL FACILITY NAMEEMS SERVICE NAMEEMS RUN NO. <br />L21031656 <br />Agency Case No. <br />