Form 735-32 - Oregon Traffic Accident And Insurance Report Page 6
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7MOTOR CARRIER CRASH REPORT
OREGON DEPARTMENT OF
TRANSPORTATION ACCIDENT REPORTING
UNIT DRIVER AND MOTOR VEHICLE SERVICES
1905 LANA AVE. NE
SALEM OR 97314
FAX: (503) 945-5267
INSTRUCTIONS: IF YOU CHECKED A BOX UNDER THE QUALIFYING VEHICLE COLUMN AND A BOX UNDER THE CRITERIA COLUMN, COMPLETE THE REMAINDER OF
THE MOTOR CARRIER CRASH REPORT AND SUBMIT TO THE ADDRESS SHOWN ABOVE. IF NO CIRCUMSTANCES LISTED UNDER THE CRITERIA COLUMN APPLY, YOU
ARE NOT REQUIRED TO SUBMIT THE MOTOR CARRIER CRASH REPORT. IF YOU HAVE ANY QUESTIONS REGARDING FILLING OUT THE MOTOR CARRIER CRASH
REPORT, PLEASE CALL (503) 986-3507.
QUALIFYING VEHICLE
CRITERIA
COMMERCIAL TRUCK (GVWR OVER 10,000 LBS OR ACTUAL WT
ANY PERSON SUSTAINING A FATALITY (WITHIN 30 DAYS OF THE
AT TIME OF CRASH EVEN IF GVWR IS SET UNDER 10,000 LBS )
ACCIDENT)
HAZARDOUS MATERIAL PLACARD
ANY PERSON SUSTAINING INJURIES REQUIRING TREATMENT AWAY
COMMERCIAL BUS (DESIGNED FOR 8 OR MORE PASSENGERS)
FROM THE SCENE
FARM TRUCK INTERSTATE (OVER 10,000 LBS.)
ANY VEHICLE INCURRING DISABLING DAMAGE REQUIRING
FARM TRUCK FOR-HIRE (4 OR MORE AXLES)
REMOVAL FROM THE SCENE BY A TOW TRUCK OR ANOTHER
FARM TRUCK TOWING TRIPLE TRAILERS
MOTOR VEHICLE
FARM TRUCK (OVER 80,000 LBS.)
MOTOR CARRIER NAME
US DOT NUMBER
AUTHORITY/FILE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
DRIVER INFORMATION
DRIVER NAME (LAST, FIRST, MIDDLE)
DATE OF BIRTH
LENGTH OF EMPLOYMENT
YEARS
MONTHS
CDL / DL NUMBER
STATE
LICENSE CLASS
EXPIRATION DATE OF MEDICAL CERTIFICATE
A
B
C
D
M
COMPLETE THE FOLLOWING TWO QUESTIONS AS IF DOING A RECAP OF HOURS IN TIME DOCUMENTS AT TIME OF THE ACCIDENT.
AT TIME OF THE ACCIDENT, TOTAL HOURS
TOTAL HOURS ON DUTY DURING THE PREVIOUS
7 CONSECUTIVE DAYS ____________
DRIVING SINCE LAST OFF-DUTY PERIOD.
(FILL OUT ONE ONLY, BASED ON TIME DOCUMENTS)
8 CONSECUTIVE DAYS ____________
TYPE OF WAIVER (SIGHT, DIABETES, AMPUTEE, ETC.)
DOES YOUR DRIVER HAVE A MEDICAL WAIVER
YES
NO
DRIVER INJURY INFORMATION
YOUR DRIVER KILLED
YOUR DRIVER INJURED
RELIEF DRIVER KILLED
RELIEF DRIVER INJURED
TOTAL NUMBER OF PASSENGERS
YES
NO
YES
NO
YES
NO
YES
NO
_____KILLED
_____ INJURED
OTHER DRIVER INJURY INFORMATION
TOTAL NUMBER OF OTHER DRIVERS
TOTAL NUMBER OF OTHER PASSENGERS
TOTAL NUMBER OF PEDESTRIANS
TOTAL NUMBER OF BICYCLISTS
_____KILLED
_____ INJURED
_____KILLED
_____ INJURED
_____KILLED
_____ INJURED
_____KILLED
_____ INJURED
OTHER MOTOR CARRIER INFORMATION
(IF 2 OR MORE MOTOR CARRIERS WERE INVOLVED)
MOTOR CARRIER NAME
VEHICLE LICENSE # AND STATE
DRIVER'S NAME
DRIVER'S LICENSE # AND STATE
MOTOR CARRIER VEHICLE INFORMATION
YEAR
MAKE
UNIT NUMBER
TRUCK/TRACTOR/BUS LICENSE PLATE NO. & STATE
TOTAL NO. OF AXLES
I
NCLUDING TRAILERS
VEHICLE TYPE (SELECT APPROPRIATE
TYPE)
Heavy Haul
Standard
5
1
Triples (tractor with 3 trailers
9
Tractor/Semi Trailer
Bus/Van (8 or more
6
2
Straight Truck
10
Triples (truck with 2 trailers)
passenger capacity)
7
3
11
Auto/Pickup
Bobtail
Straight truck-full trailer
8
4
Saddlemount
Doubles (any)
735-9229 (4-15)
COMPLETE REVERSE SIDE
SUPPLEMENTAL – MOTOR CARRIER CRASH REPORT
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