Form 735-32 - Oregon Traffic Accident And Insurance Report Page 4
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1
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7YOU INTENDED TO...
YOUR VEHICLE
WEATHER CONDITIONS
YOUR RESIDENCE
Go straight ahead
Passenger car, pickup, van
Clear
Local resident
Make right turn
Military vehicle
Raining
(within 25 miles of accident site)
Make left turn
Taxicab
Snowing
Residing elsewhere in state
Make “U” turn
Emergency vehicle
Fog
Non–resident of this state:
Back–Up
Any of the above and trailer
Other
College student
Enter driveway (also
Private or public agency
Military
ROAD SURFACE
mark left or right turn)
transit vehicle
Temporary job
Dry
Remain stopped in traffic
Bus
YOU WERE HEADED
Wet
Enter parked position
School bus
Snowy
North
East
Slow or Stop
Other publicly-owned veh.
Icy
South
West
Leave driveway (also
Motorcycle
Other
On: ____________________
mark left or right turn)
Motor–scooter/bike
LIGHT CONDITIONS
(name of street, road or route)
Start in traffic lane
Personal (assisted) mobility device
Daylight
OTHER DRIVER WAS HEADED
Leave parked position
Truck tractor & semi trailer
Dawn or dusk
North
East
Remain parked
Truck/truck tractor
Darkness (lighted)
South
West
Overtake and pass
Other truck combination
Darkness (unlighted)
Farm tractor/farm equip.
On: ____________________
Other
(name of street, road or route)
WITNESS INFORMATION:
If this accident involved a pedestrian or
bicyclist, complete the following:
PEDESTRIAN NAME
BICYCLIST NAME
Pedestrian or bicyclist was going:
DRIVER AND PASSENGER INJURY AND SAFETY EQUIPMENT INFORMATION
N
S
E
W
SAFETY EQUIPMENT CODES
INJURY CODE FOR OCCUPANTS
ALONG OR ACROSS:
(name of street, road or route)
WRITE one of the codes (0–10) in column C
WRITE one of the codes (1–5) in column D
1.
Deceased as a result of the accident
0
No seat belt available
From:
2.
1
Seat belt available but NOT used
Incapacitated - unconscious, could not walk,
2
Seat belt available and in use
broken or distorted limbs, etc.
To:
3
Child restraint device available
3.
Visible injury - lump, abrasion cuts
4
Child restraint device in use
4.
Momentary unconsciousness, complaint of
5
Child restraint device not available
pain, nausea, limping
(From: NE corner To: SE corner (or) From: East side To: West side, etc.)
EXAMPLE:
6
Helmet NOT in use
5.
No apparent injury
Sex and age of pedestrian / bicyclist:
7
Helmet in use
M
F
X
Age: _____
8
Air bag deployed
9
Air bag available - NOT deployed
SEX CODE
Extent of pedestrian / bicyclist injury:
10
Air bag NOT available
WRITE M, F or X in column A
Deceased
Momentary unconscious-
A
B
C
D
SEAT
ness / complaint of pain
PASSENGER’S NAMES (your vehicle)
Incapacitated
SFTY
AIR
POSITION
SEX
AGE
INJURY
EQP
BAG
No apparent injury
Visible injury
DRIVER
Pedestrian / bicyclist action: (mark one)
FRONT
CENTER
Crossing at intersection or crosswalk
FRONT
Crossing not at intersection or crosswalk
RIGHT
*
Walking / riding in roadway with traffic
MIDDLE
LEFT
Walking / riding in roadway against traffic
*
MIDDLE
Standing in roadway
CENTER
*
MIDDLE
Pushing or working on vehicles in roadway
RIGHT
Other working in road
REAR
LEFT
Playing in road
REAR
Hitchhiking
CENTER
Not in roadway
REAR
RIGHT
Other________________________________
*
Use only for vehicles with middle row of seats (i.e., vans, SUVs, etc.)
(specify)
Vehicle Damage
Diagram
Number each vehicle:
Show path by:
Show pedestrian/bicyclist by:
Show railroad tracks by:
USE ARROW TO SHOW
Vehicle towed
FIRST IMPACT (SHADE
Rollover
IN DAMAGED AREA)
Under car
Totaled
Unknown
(name of street,
(name of street,
Your Vehicle (No. 1) damage: $ __________ .
road or route)
road or route)
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Parent category: Legal