Sample Form Fr300p - Police Crash Report Page 6
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6Commonwealth of Virginia
Department of Motor Vehicles
FR300P (Rev 1/12)
•
Officer Initials________ Badge # __________
Police Crash Report
Page _______ of _______
Revised Report
CRASH
Crash
MM DD YYYY
MILITARY Time (24 hr clock) County of Crash
Local Case Number
City of
Date
Town of
PEDESTRIAN #
PEDESTRIAN #
Name of Injured (Last, First, Middle)
Name of Injured (Last, First, Middle)
Address (Street and Number)
Address (Street and Number)
City
State
ZIP
City
State
ZIP
Driver’s License #
State
Driver’s License #
State
Gender
EMS Transport
Injury Type
Birthdate
Date of Death
Gender
EMS Transport
Injury Type
Birthdate
Date of Death
M
F
MM
DD
YYYY
MM
DD
YYYY
M
F
MM
DD
YYYY
MM
DD
YYYY
Y
N
Y
N
Ped #
Ped #
Ped #
Ped #
Ped #
Ped #
Ped #
Ped #
Pedestrian Actions
Pedestrian Drinking
Method of
P10
P11
P13
N/A
N/A
N/A
N/A
N/A
N/A
Alcohol
1. Crossing At Intersection
11. Hitching On Vehicle
1. Had Not Been Drinking
Determination
With Signal
12. Walking In Roadway
2. Drinking-Obviousl y Drunk
by Police
2. Crossing At Intersection
With Traffic – Sidewalks
3. Drinking -Ability Impaired
Against Signal
Avail able
4. Drinking -Ability Not Impaired
3. Crossing At Intersection
1. Blood
13. Walking In Roadway
5. Drinking -Not Known
No Signal
With Traffic – Sidewalks
2. Breath
Whether Impaired
Not Available
4. Crossing At Intersection
3. Refused
Diagonally
14. Walking In Roadway
Condition of
P12
4. No Test
N/A
N/A
Against Traffic
5. Crossing Not At
Pedestrian
– Sidewalks Available
Intersection – Rural
Pedestrian Drug Use
P14
Contributing to
N/A
N/A
15. Walking In Roadway
6. Crossing Not At
the Crash
Against Traffic – Side
Intersection – Urban
1. Yes
Walks Not Available
2. No
7. Coming From Behind
1. No Defects
16. Working In Roadway
Parked Cars
3. Unknown
2. Eyesight Defective
17. Standing In Roadway
8. Getting Off Or On
3. Hearing Defective
Pedestrian Wear
School Bus
P15
18. Lying In Roadway
N/A
N/A
4. Other Body Defects
Reflective Clothing
9. Playing In Roadway
19. Not In Roadway
5. Illness
10. Getting Off Or On
20. Other
1. Yes
Another Vehicle
6. Fatigued
2. No
7. Apparently Asleep
8. Other
Use sections below for additional passengers.
VEHICLE #
VEHICLE #
PASSENGER
PASSENGER
(only if injured or killed)
(only if injured or killed)
Name of Injured (Last, First, Middle)
EMS Transport
Date of Death
Name of Injured (Last, First, Middle)
EMS Transport Date of Death
Y
N
Y
N
MM
DD
YY
MM
DD
YY
Position
Safety
Airbag Ejected Injury Type
Birthdate
Gender
Position
Safety
Airbag Ejected Injury Type
Birthdate
Gender
In/On
Equip
In/On
Equip
M
F
M
F
Vehicle
Used
MM
DD
YYYY
Vehicle
Used
MM DD
YYYY
Name of Injured (Last, First, Middle)
EMS Transport
Date of Death
Name of Injured (Last, First, Middle)
EMS Transport Date of Death
Y
N
Y
N
MM
DD
YY
MM
DD
YY
Position
Safety
Airbag Ejected Injury Type
Birthdate
Gender
Position
Safety
Airbag Ejected Injury Type
Birthdate
Gender
In/On
Equip
In/On
Equip
M
F
M
F
Vehicle
Used
MM
DD
YYYY
Vehicle
Used
MM DD
YYYY
Name of Injured (Last, First, Middle)
EMS Transport
Date of Death
Name of Injured (Last, First, Middle)
EMS Transport Date of Death
Y
N
Y
N
MM
DD
YY
MM
DD
YY
Position
Safety
Airbag Ejected Injury Type
Birthdate
Gender
Position
Safety
Airbag Ejected Injury Type
Birthdate
Gender
In/On
Equip
In/On
Equip
M
F
M
F
Vehicle
Used
MM
DD
YYYY
Vehicle
Used
MM DD
YYYY
Codes
POSITION IN/ON VEHICLE
SAFETY EQUIPMENT USED
AIRBAG
EJECTED FROM VEHICLE
INJURY TYPE
1.
Driver
1. Lap Belt Only
1. Deployed – Front
1. Not Ejected
1. Dead
8
2-6. Passengers
2. Shoulder Belt Only
2. Not Deployed
2. Partially Ejected
2. Serious Injury
7.
Cargo Area
3. Lap and Shoulder Belt
3. Unavailable/Not Applicable
3. Totally Ejected
3. Minor/Possible Injury
8.
Riding/Hanging
4. Child Restraint
4. Keyed Off
4. No Apparent Injury
1
2
3
On Outside
5. Helmet
5. Unknown
SUMMONS ISSUED AS
4
5
6
8
8
9-98. All Other
6. Other
6. Deployed – Side
A RESULT OF CRASH
7
Passengers
7. Booster Seat
7. Deployed – Other (Knee,
1. Yes
8. No Restraint Used
Air Belt, etc.)
2. No
8
9. Not Applicable
8. Deployed – Combination
3. Pending
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