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EMS RUN NO.P10 NAME OF PERSON INVOLVED (Last, First, Middle)Restraint System / Helmet UseInjurySeating PositionPerson TypeP10 NAME OF PERSON INVOLVED (Last, First, Middle)Restraint System
<br /> / Helmet UseInjurySeating PositionPerson TypeP10 NAME OF PERSON INVOLVED (Last, First, Middle)Restraint System / Helmet UseInjurySeating PositionPerson Type99P1. Incident Responder?PERSON
<br /> TYPE02 - No01 - YesP2. If yes, type of Incident Responder99 - Unknown98 - Other safety service operators, etc.)05 - Transportation (maintenance workers,04 - Tow Operator03 - Police02
<br /> - Fire01 - EMSDoes the crash involve a Non-Motorist?02 - No – Continue to P3 below. - Unknown Type of Non-Motorist** Transportation Device - Occupant of a Non-Motor
<br /> Vehicle conveyance, etc.) parked vehicle, or a personal skater, person in a building, - Other Pedestrian (wheelchair, - Pedestrian -
<br /> Other Cyclist - Bicyclist person types: NDOT Form 178 for the following01 - Yes – Complete Non-Motorist ReportP3. Occupant of Motor Vehicle03 - Occupant of MV Not in
<br /> Transport01 - DriverP4. RowSEATING POSITION99 - Unknown 15-passenger van, etc.)05 - Other Row (bus,04 - Fourth03 - Third02 - Second01 - FrontP5. Seat99 - Unknown98 - Other03 -
<br /> Right02 - Middle01 - LeftP6. Other Location99 - Unknown98 - Other97 - Not Applicable05 - Unenclosed Cargo Area04 - Trailing Unit (truck)03 - Sleeper Section of Cab Exterior
<br /> (non-trailing unit)02 - Riding on Motor Vehicle01 - Enclosed Cargo Area99 - Unknown97 - Not Applicable03 - Ejected, Totally02 - Ejected, Partially01 - Not EjectedP8. Restraint SystemRESTRAINT
<br /> SYSTEM / HELMET USE11 - Wheelchair10 - Stretcher09 - Shoulder Belt Only Used08 - Shoulder & Lap Belt Used07 - Restraint Used - Type Unknown06 - None Used - Motor Vehicle Occupant05
<br /> - Lap Belt Only Used04 - Child Restraint System - Type Unknown03 - Child Restraint System - Rear Facing02 - Child Restraint System - Forward Facing01 - Booster SeatMotorcycle Helmet
<br /> Use99 - Unknown98 - Other97 - Not Applicable15 - No Helmet14 - Unknown If DOT-Compliant Motorcycle Helmet13 - Non DOT-Compliant Motorcycle Helmet12 - DOT-Compliant Motorcycle HelmetP9.
<br /> Any Indication of Improper Restraint Use?99 - Unknown02 - No01 - YesP10. Air Bag Deployed99 - Unknown98 - Other (knee, air belt, etc.)97 - Not Applicable04 - Side03 - Front02 - Curtain00
<br /> - Not Deployed(up to 4 choices)P11. School Bus Restraint Availability99 - Unknown97 - Not Applicable02 - Shoulder & Lap Available & Not Used01 - Lap Belt Available & Not Used00 - No
<br /> Restraint Available(excludes driver)P12. Injury StatusINJURY99 - Unknown04 - Possible Injury03 - Suspected Minor Injury02 - Suspected Serious Injury* NDOT Form 179\]01 - Fatal
<br /> Injury \[must complete Fatal Crash Report00 - No Apparent Injury taken from the crash scene, or paralysis. or more of the body), unconsciousness when burns (second and third degree
<br /> burns over 10% than bruises or minor lacerations, significant suspected skull, chest, or abdominal injury other distorted extremity (arm or leg), crush injuries, resulting in significant
<br /> loss of blood, broken or of underlying tissues, muscle, organs, or following: Severe laceration resulting in exposure fatal, which results in one or more of the* Suspected Serious
<br /> Injury: Any injury, other thanP13. Injury Area99 - Unknown10 - Unspecified09 - Upper Extremity (arms)08 - Chest (thorax)07 - Spine06 - Neck05 - Lower Extremity (legs)04 - Head03 - Face02
<br /> - Entire Body01 - Abdomen & Pelvis00 - None First Medical FacilityP14. Source of Transport to99 - Unknown98 - Other03 - Law Enforcement02 - EMS Ground01 - EMS Air00 - Not Transported
<br /> All Drivers & Occupants ofSheet Investigator’s Motor Vehicle Crash Report - All Drivers & Occupants L23112651Agency Case No.L 1 Vehicle No.1 WEBER, SOFIA, A 02 SEX01 - Male 02 -
<br /> Female 99 - Unk.ADDRESS HASTINGS, NE, 68901 CITY, STATE, ZIP██/██/2004 DATE OF BIRTH (MMDDYYYY)DOB Unk.2 P1P2 01 P3 01 P4 01 P5 97 P6 01 P7 08 P8 02 P9 0097 P11 00 P12 00 P13 00
<br /> P14MEDICAL FACILITY NAMEEMS SERVICE NAMEEMS RUN NO.2 Vehicle No.1 OWENS, RICHARD, G 01 SEX01 - Male 02 - Female 99 - Unk.801 14TH ST ADDRESS CENTRAL CITY, NE, 68826 CITY, STATE,
<br /> ZIP██/██/1942 DATE OF BIRTH (MMDDYYYY)DOB Unk.2 P1P2 01 P3 01 P4 01 P5 97 P6 01 P7 08 P8 02 P9 0097 P11 03 P12 09 P13 00 P14MEDICAL FACILITY NAMEEMS SERVICE NAMEEMS RUN NO.Vehicle No.SEX01
<br /> - Male 02 - Female 99 - Unk.ADDRESS CITY, STATE, ZIP DATE OF BIRTH (MMDDYYYY)DOB Unk.P1P2P3P4P5P6P7P8P9P11P12P13P14MEDICAL FACILITY NAMEEMS SERVICE NAME
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