Minnesota Motor Vehicle Accident Report Page 2
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1
2The information in this report is used to help build safer roads.
MAIL A COPY OF THIS REPORT TO:
DVS/ACCIDENT RECORDS
Every driver in a crash involving $1,000 or more in property damage, or injury or death,
445 MINNESOTA STREET, SUITE 181
MUST COMPLETE this form and send it to Driver and Vehicle Services within 10 days.
ST. PAUL
MN
55101-5181
Failure to provide this information is a misdemeanor under Minnesota Statute 169.08
- EJECTION CODES -
- OCCUPANT SEAT POSITION CODES -
- RESTRAINT DEVICE CODES -
0 - NOT APPLICABLE
1 - FRONT LEFT
1 - SEAT BELT NOT INSTALLED
1 - TRAPPED, EXTRICATED
2 - FRONT CENTER
2 - SEAT BELT INSTALLED, NOT USED
2 - PARTIALY EJECTED
3 - FRONT RIGHT
3 - SEAT BELT INSTALLED, USED
3 - EJECTED
4 - SECOND SEAT LEFT
4 - SEAT BELT INSTALLED, IMPROPERLY USED
4 - NOT EJECTED
5 - SECOND SEAT CENTER
5 - AUTOMATIC BELT INSTALLED, USED
6 - SECOND SEAT RIGHT
6 - AUTOMATIC BELT INSTALLED, CIRCUMVENTED
7 - THIRD SEAT LEFT
7 - AIRBAG USED WITH SEATBELT
- INJURY CODES -
8 - THIRD SEAT CENTER
8 - AIRBAG USED WITHOUT SEATBELT
K - KILLED
9 - THIRD SEAT RIGHT
9 - CHILD RESTRAINT NOT INSTALLED
A - VISIBLE SIGNS OF INJURY, AS
10 - OUTSIDE OF VEHICLE
10 - CHILD RESTRAINT INSTALLED, NOT USED
BLEEDING WOUND OR DISTORTED
11 - STOPPED IN TRAFFIC
11 - CHILD RESTRAINT INSTALLED, USED
MEMBER, OR HAD TO BE CARRIED
12 - MOTORCYCLE/SNOWMOBILE/BICYCLE DRIVER
12 - CHILD RESTRAINT IMPROPERLY USED
FROM THE SCENE
13 - MOTORCYCLE/SNOWMOBILE/BICYCLE PASSENGER ON UNIT
13 - HELMET NOT USED
B - OTHER VISIBLE INJURY, AS
90 - OTHER (DESCRIBE)
14 - HELMET USED
BRUISES, ABRASIONS, SWELLING,
90 - OTHER (DESCRIBE)
LIMPING, ETC.
C - NO VISIBLE INJURY BUT
COMPLAINT OF PAIN OR MOMENTARY
UNCONCIOUSNESS
N - NO INDICATION OF INJURY
X - UNKNOWN
YES
DRIVER: Were you on work status?
*CODES ARE ABOVE ON THIS PAGE
NO
V
P
1. NAME
CITY
STATE
AGE
SEX
SEAT*
RESTRAINT*
EJECTION*
INJURY*
E
A
H
S
2. NAME
CITY
STATE
AGE
SEX
SEAT*
RESTRAINT*
EJECTION*
INJURY*
1
S
V
P
1. NAME
CITY
STATE
AGE
SEX
SEAT*
RESTRAINT*
EJECTION*
INJURY*
E
A
H
S
2
S
2. NAME
CITY
STATE
AGE
SEX
SEAT*
RESTRAINT*
EJECTION*
INJURY*
DESCRIBE ACCIDENT IN SUFFICIENT DETAIL TO DISCLOSE CAUSES. This is a confidential report for department use only.
INDICATE NORTH
DIAGRAM WHAT HAPPENED
BY ARROW
NAME
ADDRESS
PHONE
(
)
NAME
ADDRESS
PHONE
(
)
NAME
ADDRESS
PHONE
(
)
EMPLOYEE’S SIGNATURE
WORK ADDRESS
PHONE
(
)
SAFETY OFFICERS SIGNATURE (OPTIONAL)
WORK ADDRESS
PHONE
(
)
SUPERVISOR’S NAME
WORK ADDRESS
PHONE
(
)
CHECK IF PHOTOS WERE TAKEN
BY WHOM?
(JULY 2010)
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