Form Aa-600 - Driver'S Accident Report
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4AA-600 (11-09)
COMMONWEALTH OF PENNSYLVANIA
Driver’s Accident Report
FORWARD THIS REPORT WITHIN 5 DAYS TO THE PENNSYLVANIA DEPARTMENT OF TRANSPORTATION,
BUREAU OF HIGHWAY SAFETY AND TRAFFIC ENGINEERING, P.O. Box 2047, HARRISBURG, PA 17105-2047
Pennsylvania Vehicle Code, Section 3747 states: All reports are confidential, not available as trial evidence
J
Date of Accident (Month - Day - Year)
County
Day of Week
Hour (AM - PM)
Check if Hit-Run
SEVERITY :
Was Towing Required?
Number of Vehicles Involved
Number Injured
Number Killed
J
J
J
J
UNIT 1:
YES
NO
UNIT 2:
YES
NO
TO PROPERLY LOCATE ACCIDENTS, USE AS
City - Borough - Township
On: (Street Name or Highway Number)
LANDMARKS; SR SEGMENT NUMBERS,
At Intersection With:
If Not At Intersection : _______ Feet
N S E W
MILEPOSTS; INTERSECTION OF TWO HIGH-WAYS;
Of Station Marker - Intersection - Etc…
CITY, BOROUGH, TOWNSHIP, OR COUNTY LINES.
Operator’s Name (First, Middle, Last)
Date of Birth
Operator’s License Number and State
Mr.
Mrs.
Miss
Address (Street, City, State, Zip Code)
Vehicle License Number and State
Owner’s Name (First, Middle, Last)
Year
Make
Model
Mr.
Mrs.
Miss
Address (Street, City, State, Zip Code)
PA TITLE OR OUT-OF-STATE VIN
USE THE FOLLOWING SECTION TO RECORD VEHICLE NUMBER 2, PEDESTRIAN, OR OTHER PROPERTY
Operator’s Name (First, Middle, Last)
Date of Birth
Operator’s License Number and State
Mr.
Mrs.
Miss
Address (Street, City, State, Zip Code)
Vehicle License Number and State
Owner’s Name (First, Middle, Last)
Year
Make
Model
Mr.
Mrs.
Miss
Address (Street, City, State, Zip Code)
PA TITLE OR OUT-OF-STATE VIN
J
Description of Damaged Property
Check If State Owned Property
IF MORE VEHICLES/PEDESTRIANS/OCCUPANTS ARE INVOLVED USE ADDITIONAL REPORTS.
INJURY
SEATING
ACTIVE
PASSIVE
NAME
AGE SEX
VEH.NO.
INJURY CLASS
ACTIVE RESTRAINT
TYPE
POSITION RESTRAINT RESTRAINT
0 - N
I
0 - N
O
NJURY
ONE
1 - D
1 - S
H
EATH
HOULDER
ARNESS
2 - M
I
O
AJOR
NJURY
NLY
3 - M
I
2 - S
B
O
ODERATE
NJURY
EAT
ELT
NLY
4 - M
I
3 - C
INOR
NJURY
OMBINATION
9 - U
(H
& B
)
NKNOWN
ARNESS
ELT
4 - C
R
HILD
ESTRAINT
POSITION
7 - M
H
OTORCYCLE
ELMET
1 - D
8 - O
RIVER
THER
2-6 - P
9 - U
ASSENGER
NKNOWN
7 - P
EDESTRIAN
8 - O
THER
PASSIVE RESTRAINT
0 - N
P
ONE OR
EDESTRIAN
1 - A
(D
)
IRBAG
EPLOYED
1
2
3
2 - A
(N
D
)
IRBAG
OT
EPLOYED
4
5
6
3 - A
S
B
UTOMATIC
EAT
ELT
8 - O
THER
9 - U
NKNOWN
Insurance
Insurance
Company
Company
Information
Information
Unit 1
Policy No.
Unit 2
Policy No.
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