Alaska Motor Vehicle Crash Form 12-209
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1
2ALASKA MOTOR VEHICLE CRASH FORM 12-209
DMV #
C R A S H I N F O R M A T I O N
(One choice per field unless otherwise noted. Other* should be explained in narrative)
Total # Vehicles
Crash Date
Time of Crash
Crash Day
Crash occurred in (City / Borough)
am
01 MON
03 WED
05 FRI
07 SUN
pm
02 TUE
04 THU
06 SAT
Name of Street or Highway
Name of Cross Street, Highway, Bridge, etc.
OFFICIAL USE ONLY
North of:
South of:
Miles
Location Control
Reference Point
East of:
West of:
Feet
At intersection with:
Weather
Lighting
Roadway / Junction
01 Blowing dirt, snow
07 Sleet, hail (freezing rain)
01 Dark - lighted roadway
07 Not reported
01 Crossover
07 Roundabout
13 Other*
02 Clear
08 Severe crosswinds
02 Dark - not lighted
08 Unknown
02 Driveway
08 T - intersection
03 Cloudy
09 Snow
03 Dark - unknown lighting
03 Not a junction
09 Y - intersection
04 Fog/ smoke
10 Other*
04 Daylight
04 On ramp
10 Four way intersection
05 Ice fog
11 Not reported
05 Twilight
05 Off ramp
11 Five point or more
06 Rain
12 Unknown
06 Other*
06 Railway crossing
12 Unknown
First Sequence of Events (what was the first thing you crashed into, or what was the first event that resulted in the crash. (CHECK ONLY ONE FOR EITHER COLLISION OR NON-COLLISION
COLLISION
NON-COLLISION
01 Aircraft
09 Ditch
17 Median barrier
25 Train
33 Cargo loss / shift
40 Overturn
02 Animal
10 Embankment
18 Moose
26 Tree / shrub
34 Crossed median / centerline
41 Ran off road
03 Bicyclist
11 Fence
19 Parked vehicle
27 Utility pole
35 Downhill runaway
42 Separation of units
04 Bridge / overpass
12 Guard rail face
20 Pedestrian
28 Vehicle in transit
36 Equipment failure
43 Other*
05 Bridge rail
13 Guard rail end
21 Sideswipe
29 Vehicle - rear end
37 Explosion / fire
44 Unknown
06 Crash cushion
14 Light support
22 Sign
30 Vehicle - head on
38 Immersion
07 Culvert
15 Machinery
23 Snowberm
31 Vehicle - angle
39 Jackknife
08 Curb / wall
16 Mail box
24 Traffic signal pole
32 Other fixed object
Location of First Sequence of Events (where did the crash happen first?)
Road Surface
Did police
10 Unknown
01 Dry
07 Wet
Yes
01 Bike lane
04 Outside of trafficway
07 Roadway
04 Sand, mud, oil
investigate
02 Gore
05 Parking lot
08 Shared use paths
02 Ice
05 Slush
08 Other*
No
this crash?
03 Median
06 Roadside
09 Shoulder
03 Water
06 Snow
Y O U R D R I V E R I N F O R M A T I O N
Your Name (Vehicle Driver's Last Name, First Name, Middle Name)
Your Date of Birth
Your Contact Telephone
Your Mailing Address
Your Driver License Number
Your Driver License State
Your Driver License Country
Your City
Your State
Your Zip Code
Your Residence Country
Y O U R V E H I C L E I N F O R M A T I O N
Your Vehicle Owner's Name (Last, First, Middle Initial)
Vehicle Owner's Telephone
Your Vehicle Damage
No. of Occupants
01 None / minor
03 Disabling
05 Unknown
Your Vehicle Owner's Mailing Address
02 Functional
04 Totaled
02
03
04
Your Vehicle Owner's City
Your Vehicle Owner's State
Vehicle Owner's Zip Code
Vehicle Year
Vehicle Make
Vehicle Model
License Plate #
Vehicle License State
01
05
Your Vehicle's Direction of Travel
Damage Estimate
01 North
02 South
03 East
04 West
05 Unknown
Over $501
Your Vehicle Driver's Injury Status (vehicle passengers are listed on page 2)
08
07
06
01 Fatal
03 Non-incapacitating
05 None
07 Unknown
02 Incapacitating
04 Possible
06 Not reported
CHECK ONLY ONE TO SHOW FIRST AREA OF IMPACT
Roadway Circumstances (that may have contributed to the crash)
Your Vehicle Action
01 Debris
07 Road surface condition
13 Other*
01 Avoiding objects in road
08 Out of control
15 Straight ahead
02 Inoperative traffic device
08 Ruts, holes, bumps
14 Unknown
02 Backing
09 Passing
16 Turning right
03 Missing traffic device
09 School zone
03 Changing lanes
10 Parked
17 Turning left
04 Obscured traffic device
10 Work zone
04 Entering traffic lane
11 Skidding
18 Other*
05 Obstruction in roadway
11 Worn, polished road surface
05 Leaving traffic lane
12 Slowing
19 Unknown
06 Shoulder
12 None
06 Making U-turn
13 Starting in traffic
07 Merging
14 Stopped
Traffic Control
Vehicle Configuration
01 Flashing signal
05 School zone signs
09 Officer / Flagman / Guard
01 Dog sled
05 Off highway vehicle
09 Other*
02 No traffic controls
06 Stop sign
10 Yield sign
02 Light truck (4 tires)
06 Passenger car
10 Unknown
03 Road construction signs
07 Traffic control signal
11 Other*
03 Motorhome
07 Pedalcycle
04 RR crossing device
08 Warning signs
12 Unknown
04 Motorcycle
08 Pedestrian
C R A S H D E S C R I P T I O N (Write a brief narrative describing the crash)
Fairbanks Police Department Rev. 07/05
Crash Form 12-209 - Page 1
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