Commonwealth Of Massachusetts Motor Vehicle Crash Operator Report

Section F: Crash Conditions
Commonwealth of Massachusetts
Light Conditions
Weather Conditions (up to two)
Traffic Control Device
Was the traffic
Road Surface
Roadway Intersection Type
1
Daylight
1
Clear
1
No controls
control device
1
Dry
Motor Vehicle Crash Operator Report
2
Dawn
2
Cloudy
2
Stop signs
functioning at
2
Wet
3
Dusk
3
Rain
3
Traffic control signal
the time of the
3
Snow
1
Not at intersection
When Should You File a Report
4
Dark - lighted roadway
4
Snow
4
Flashing traffic control signal
crash?
4
Ice
2
Four-way intersection
n
5
Dark - roadway not lighted
5
Sleet, hail, freezing rain
5
Yield signs
5
Sand, mud, dirt, oil, gravel
You should file a report if you’re the operator of a vehicle involved in a crash where the damage to any one vehicle or
3
T-intersection
6
Dark - unknown roadway
6
Fog, smog, smoke
6
School zone signs
1
___ Yes
6
Water (standing, moving)
4
Y-intersection
property is over $1000, or if there is an injury to any person, even if a police officer was on the scene. You should file
lighting
7
Severe crosswinds
7
Warning signs
7
Slush
5
On ramp
the report within 5 days of the date of the crash.
9 7 Other
8
Blowing sand, snow
8
Railroad crossing device
2
___ No
9 7 Other
6
Off ramp
9 9 Unknown
9 7 Other
9 9 Unknown
9 9 Unknown
When Should You NOT File a Report
7
Traffic circle
9 9 Unknown
n
You should not file a report if the crash occurred on a private road, driveway, private parking lot or other private way.
8
Five-point or more
Trafficway Description
School Bus
Work Zone
Manner of Collision
9
Driveway
Why this Report is Important
1
Two-way, not divided
Related?
Related?
1 Single vehicle crash
6
Head on
10 Railway grade crossing
2
Two-way, divided, unprotected median
2 Rear-end
7
Rear to rear
Data from this report is used for many purposes including:
99 Unknown
3
Two-way, divided, protected median
1
___ Yes
1
___ Yes
3 Angle
9 9 Unknown
n
Identifying locations with a large number of crashes.
4
One-way, not divided
4 Sideswipe, same direction
n
2
___ No
2
___ No
Improving dangerous highways and intersections.
9 9 Unknown
5 Sideswipe, opposite direction
n
Developing highway safety public information programs.
n
Section G: Crash Diagram
Developing programs to save lives and reduce highway injuries.
Please draw a diagram of the
roadway or streets where the crash
occurred, indicating the vehicles
How To Complete This Form
involved and direction of travel
Indicate
Please carefully complete all sections of this form that apply to your crash, circling the answer where appropriate. Illegible
using the following symbols:
North by
reports will be returned to you.
Arrow
= Direction
1
= Vehicle 1 (Your Vehicle)
2
= Vehicle 2
O
= Pedestrian/Non-motorist
Section A: Crash Location
Section F: Crash Conditions
= North
n
Provide the city/town where the crash occurred,
n
Use the codes provided to indicate the
Select one of the following if
the date and time of the crash, and the number of
conditions at the time of the crash.
the crash did not occur on a
vehicles involved.
public way:
n
Complete section A1 or A2.
Section G: Crash Diagram
___ Off-street parking lot
n
___ Garage
Use official names of all locations, streets and
n
Draw a diagram of how the crash occurred.
___ Mall/shopping center
landmarks.
n
On the diagram, Vehicle 1 represents your
___ Other private way
n
Use street name and route #, if applicable.
vehicle.
n
Section H: Witness Information
Be as precise as possible when describing the
Witness Name (Last, First, Middle)
Address
Phone
location.
Section H: Witness Information
n
Provide enough information to locate the crash
n
List all the people who saw the crash but were
to a specific point, not just a street or roadway.
not involved.
Section B: Vehicle You Were Driving
Section I: Property Damage Information
Section I: Property Damage Information (Other than Vehicles)
n
Provide information on your license and the
n
Owner Name (Last, First, Middle)
Address
Phone
Property and Damage Description
Indicate all non-vehicular property that was
vehicle you were driving.
damaged in the crash.
n
Use the codes provided to indicate the cause of
the crash.
Section J: Description of What Happened
n
Describe the crash including events prior to the
Section J: Description of What Happened
Section C: You and Your Passengers
crash for your vehicles and all other vehicles.
n
Provide information on you and your passengers
at the time of the crash.
Section K: Signature
n
Use the codes provided to indicate occupant
n
Please sign and print your name and indicate the
information.
date you completed the form.
Section D: Other Vehicles Involved in the
Where to send completed reports:
Crash
n
Provide information on the other vehicle(s) and
q Mail or deliver one copy to your local police
operator(s) involved in the crash.
department in the city or town where the crash
n
If more than one vehicle involved, please use
occurred.
additional form completing Section D only.
q Mail one copy to your Insurance Company.
Section E: Non-Motorist(s) Involved
q Mail one copy to the RMV at the following
n
Provide information on the non-motorist(s)
address:
Section K: Signature
involved in the crash.
Crash Records
_______________________________________________
Print ________________________________________
Date ___________________________
n
If more than one non-motorist involved, please
Registry of Motor Vehicles
“Signed under Pains and Penalties of Perjury”
use additional form completing Section E only.
P.O. Box 55889
Boston, MA 02205-5889
CRA-23 #10365 G003402 05/02 MCI
Page 1
Page 4

Section A: Crash Location
Section C: You and Your Passengers
City/Town Where Crash Occurred
Date of Crash
Time of Crash
# Vehicles
Please provide the full name, address, and DOB or Age for all passengers in your vehicle. Then write the corresponding code in each of the boxes for each occupant of the vehicle
____ : ____ __ AM __ PM
Involved:
(yourself and all passengers). A list of the possible codes is provided at the bottom of this section.
Date of
A B C D E F G H Name of
Sex
Please complete Section A1 or A2 below to indicate the location of the crash.
Medical Facility
Birth/Age M/F
If you need additional space to describe the crash location, please use Section J on the last page of this form.

Driver (See previous page)
SECTION A1: Complete this Section if the crash
SECTION A2: Complete this Section if the crash did NOT occur at an
OR
occurred at an intersection of two or more streets:
intersection:
Step 1: Please indicate the route or roadway where you
Step 1: Please indicate the route, roadway and address where the crash occurred:
Name of Passenger 1 (Last, First, Middle)
were travelling when the crash occurred:
The crash occurred on Route #: _______ at Street or Address Number: ________________
Address
____________ __________________________________
on the Street/Roadway known as: ______________________________________________
City/Town
State
Zip
Route# Name of Roadway/Street
Name of Passenger 2 (Last, First, Middle)
Step 2: Please provide as much of the following specific location information as possible:
Address
Step 2: What was the name (or names) of the intersecting
streets?
The crash occurred (estimate number of feet)
_______________ feet
City/Town
State
Zip
(indicate direction as N/S/E/W) _______________ of
Name of Passenger 3 (Last, First, Middle)
____________ __________________________________
a) Mile Marker number
___ ___ ___ ___
Address
Route# Name of Roadway/Street
O R : b) Exit Number
________________
City/Town
State
Zip
____________ __________________________________
A. Seating Position
B. Safety System Used
O R : c) Intersecting Street/Roadway __________ ___________________________
C. Air Bag Status
D. Air Bag Switch
Route# Name of Roadway/Street
Route# Name of Roadway/Street
1 Front seat - left side (or motorcycle driver)
9
Third row - right side
0
None used
1
Deployed-front 1
Switch in ON position
O R : d) Landmark _______________________________________________________
2 Front seat - middle
10 Sleeper section of cab
1
Shoulder and lap belt
2
Deployed-side
2
Switch in OFF position
3 Front seat - right side
11 Enclosed passenger area
2
Lap belt only
3
Deployed both
3
ON-OFF switch not present
Section B: Vehicle You Were Driving
4 Second seat - left side (or motorcycle passenger) 12 Unenclosed passenger area
3
Shoulder belt only
front and side
4
Unknown if switch is present
5 Second seat - middle
13 Trailing unit
4
Child safety seat
4
Not deployed
99 Unknown
Number of occupants in vehicle (including yourself): _________
Was vehicle damage above $1000? __Yes __No
6 Second seat - right side
14 Riding on vehicle exterior
5
Helmet
5
Not applicable
Driver’s License Number
License State Date of Birth Age Sex
License Class
Commercial Driver’s License Endorsements
7 Third row - left side (or motorcycle passenger)
97 Other
__ D __ A __B __C
H __ Hazardous
N __ Tank vehicles
P__Passenger
99 Unknown
__ M __ F
99 Unknown
__ M __ Unknown
T __ Doubles/Triples
X __ Tank and Hazardous transport
8 Third row - middle
99 Unknown
Your Full Name (Last, First, Middle)
Street Address
City/Town
State
Zip
E. Ejected From Vehicle? F. Trapped?
G. Injured?
H. Transported for Medical Care?
0
Not ejected
0
Not trapped
1
Fatal injury
1 Not transported
9 7 Other
Non-fatal injury:
Insurance Company
V e h i c l e R e g i s t r a t i o n #
Reg. Type
Reg. State
Vehicle Year
Vehicle Make
1
Totally ejected
1
Freed by mechanical means
2 EMS (emergency service)
9 9 Unknown
2
Partially ejected
2
Freed by non-mechanical means
2
Incapacitating 5 No injury
3 Police
3
Not applicable
9 9 Unknown
3
Non-incapacitating
99 Unknown
Indicate your type of vehicle
9 9 Unknown
4
Possible
Section D: Other Vehicle(s) Involved in the Crash
1 Passenger car
4 Bus (15 or more passengers)
8 Truck/trailer
12 Tractor/triples
97 Other
Was Vehicle Damage
2 Light truck (van, mini-van, 5 Bus (7-15 passengers)
9 Truck tractor (bobtail)
13 Unknown heavy truck
99 Unknown
Number of occupants in the Vehicle: _____
Number of injured occupants: _____
__Yes ___No Moped? __Yes __No Hit and Run? __Yes __No
above $1000?
pick-up, sport utility)
6 Single-unit truck (2 axles)
10 Tractor/semi-trailer
14 Motor home/recreational vehicle
Driver’s License Number
License State Date of Birth Age
Commercial Driver’s License Endorsements
Sex
License Class
3 Motorcycle
7 Single-unit truck (3 or more axles) 11 Tractor/doubles
__ D __ A __ B __ C H __ Hazardous
N __ Tank vehicles
P__Passenger
__ M __ F
_ _ M __ Unknown
T __ Doubles/Triples
X __ Tank and Hazardous transport
Full Name of Vehicle Owner (Last, First, Middle)
Street Address
City/Town
State Zip
Full Name of Vehicle Driver (Last, First, Middle)
Street Address
City/Town
State
Zip
What Was Your Vehicle Doing Prior to the Crash?
Insurance Company
Vehicle Registration #
Reg. Type
Reg. State
Vehicle Year
Vehicle Make

Vehicle Travel Direction
1 Travelling straight ahead
4 Turning left
7 Leaving traffic lane
10 Backing
97 Other
2 Slowing or stopped
5 Changing lanes
8 Making U-turn
11 Parked
99 Unknown
Indicate type of vehicle
__N __S __E __W
3 Turning right
6 Entering traffic lane 9 Overtaking/passing
1 Passenger car
4 Bus (15 or more passengers)
8 Truck/trailer
12 Tractor/triples
97 Other
2 Light truck (van, mini-van,
5 Bus (7-15 passengers)
9 Truck tractor (bobtail)
13 Unknown heavy truck
99 Unknown
Please Indicate the Sequence of Events as they occurred to YOUR Vehicle by writing the corresponding number (1-52, or 97, 99) in up to 4 boxes below.
pick-up, sport utility)
6 Single-unit truck (2 axles)
10 Tractor/semi-trailer
14 Motor home/recreational vehicle
3 Motorcycle
7 Single-unit truck (3 or more axles)
11 Tractor/doubles
What happened first?
What happened 2nd (if applicable)?
What happened 3rd (if applicable)?
What happened 4th (if applicable)?
Full Name of Vehicle Owner (Last, First, Middle)
Street Address
City/Town
State
Zip
Vehicle Travel
Vehicle Damaged Area (circle up to three)
What Was the Vehicle Doing Prior to the Crash?
Non-Collision
Direction
2
3
4
0 None
Collision with

23
Light pole or other post/support
40
Ran off road right
1 Travelling straight ahead
4 Turning left
7 Leaving traffic lane
10 Backing
97 Other
10 Undercarriage
1
Motor vehicle in traffic
1
9
5
11 Totaled
24
Guardrail
41
Ran off road left
__N __S
2 Slowing or stopped
5 Changing lanes
8 Making U-turn
11 Parked
99 Unknown
2
Parked motor vehicle
97 Other
25
Median barrier
42
Cross median/centerline
__E __W
3
Pedestrian
3 Turning right
6 Entering traffic lane
9 Overtaking/passing
8
7
6
99 Unknown
26
Ditch
43
Overturn/rollover
4
Cyclist
Section E: Non-Motorist(s) Involved in the Crash
27
Embankment/Sloping shoulder
44
Equipment failure (blown tire, brakes, etc)
5
Animal- deer
28
Highway traffic signpost
45
Fire/explosion
6
Animal- other
Indicate the type of non-motorist involved
1 Pedestrian
2 Cyclist
3 Skater
97 Other
99 Unknown
29
Overhead sign support
46
Immersion
7
Moped
What was the non-motorist doing prior to the crash?
Where was the non-motorist prior to the crash?
30
Fence
47
Jackknife
8
Work zone maintenance equipment
1 Marked crosswalk at intersection
6
Median (but not on shoulder)
31
Mailbox
48
Cargo/equipment loss or shift
1 Entering or crossing location
6
Working on vehicle
9
Railway vehicle (train, engine)
32
Crash cushion/Impact attenuator
49
Separation of units
2 Walking, running, or cycling
7
Standing
2 At intersection but no crosswalk
7
Island
10 Other movable object
33
Bridge
50
Downhill runaway
3 Working
97 Other
3 Non-intersection crosswalk
8
Shoulder
11 Unknown movable object
34
Bridge overhead structure
51
Other non-collision
4 Pushing vehicle
99 Unknown
4 In roadway
9
Sidewalk
20 Curb
35
Other fixed object (wall, building, tunnel)
52
Unknown non-collision
5 Approaching or leaving vehicle
5 Not in roadway
1 0 Shared-use path or trails
21 Tree
36
Unknown fixed object
97
Other
9 9 Unknown
22 Utility pole
99
Unknown
Date of Birth/Age
Sex
Full Name of Non-Motorist (Last, First, Middle) Street Address
City/Town
State
Zip
__M __ F
Vehicle Damaged Area
2
3
4
0 None
10 Undercarriage
Safety Equipment?
Injured?
Transported for Medical Care?
Was your Vehicle Towed From the Scene Due to Damage? __Yes __No
(circle up to three)
11 Totaled
1
9
5
0 None used
9
Lighting
1
Fatal injury
1 Not transported
9 7 Other
97 Other
6 Helmet
10 Other
Non-fatal injury:
2 EMS (emergency service)
9 9 Unknown
99 Unknown
8
7
6
7 Protective pads (elbows, knees, etc.)
99 Unknown
2
Incapacitating
5
No injury
3 Police
8 Reflective clothing
3
Non-incapacitating
99 Unknown
If transported, please indicate Hospital/Medical Facility:
4
Possible
Page 2
Page 3

Section F: Crash Conditions
Commonwealth of Massachusetts
Light Conditions
Weather Conditions (up to two)
Traffic Control Device
Was the traffic
Road Surface
Roadway Intersection Type
1
Daylight
1
Clear
1
No controls
control device
1
Dry
Motor Vehicle Crash Operator Report
2
Dawn
2
Cloudy
2
Stop signs
functioning at
2
Wet
3
Dusk
3
Rain
3
Traffic control signal
the time of the
3
Snow
1
Not at intersection
When Should You File a Report
4
Dark - lighted roadway
4
Snow
4
Flashing traffic control signal
crash?
4
Ice
2
Four-way intersection
n
5
Dark - roadway not lighted
5
Sleet, hail, freezing rain
5
Yield signs
5
Sand, mud, dirt, oil, gravel
You should file a report if you’re the operator of a vehicle involved in a crash where the damage to any one vehicle or
3
T-intersection
6
Dark - unknown roadway
6
Fog, smog, smoke
6
School zone signs
1
___ Yes
6
Water (standing, moving)
4
Y-intersection
property is over $1000, or if there is an injury to any person, even if a police officer was on the scene. You should file
lighting
7
Severe crosswinds
7
Warning signs
7
Slush
5
On ramp
the report within 5 days of the date of the crash.
9 7 Other
8
Blowing sand, snow
8
Railroad crossing device
2
___ No
9 7 Other
6
Off ramp
9 9 Unknown
9 7 Other
9 9 Unknown
9 9 Unknown
When Should You NOT File a Report
7
Traffic circle
9 9 Unknown
n
You should not file a report if the crash occurred on a private road, driveway, private parking lot or other private way.
8
Five-point or more
Trafficway Description
School Bus
Work Zone
Manner of Collision
9
Driveway
Why this Report is Important
1
Two-way, not divided
Related?
Related?
1 Single vehicle crash
6
Head on
10 Railway grade crossing
2
Two-way, divided, unprotected median
2 Rear-end
7
Rear to rear
Data from this report is used for many purposes including:
99 Unknown
3
Two-way, divided, protected median
1
___ Yes
1
___ Yes
3 Angle
9 9 Unknown
n
Identifying locations with a large number of crashes.
4
One-way, not divided
4 Sideswipe, same direction
n
2
___ No
2
___ No
Improving dangerous highways and intersections.
9 9 Unknown
5 Sideswipe, opposite direction
n
Developing highway safety public information programs.
n
Section G: Crash Diagram
Developing programs to save lives and reduce highway injuries.
Please draw a diagram of the
roadway or streets where the crash
occurred, indicating the vehicles
How To Complete This Form
involved and direction of travel
Indicate
Please carefully complete all sections of this form that apply to your crash, circling the answer where appropriate. Illegible
using the following symbols:
North by
reports will be returned to you.
Arrow
= Direction
1
= Vehicle 1 (Your Vehicle)
2
= Vehicle 2
O
= Pedestrian/Non-motorist
Section A: Crash Location
Section F: Crash Conditions
= North
n
Provide the city/town where the crash occurred,
n
Use the codes provided to indicate the
Select one of the following if
the date and time of the crash, and the number of
conditions at the time of the crash.
the crash did not occur on a
vehicles involved.
public way:
n
Complete section A1 or A2.
Section G: Crash Diagram
___ Off-street parking lot
n
___ Garage
Use official names of all locations, streets and
n
Draw a diagram of how the crash occurred.
___ Mall/shopping center
landmarks.
n
On the diagram, Vehicle 1 represents your
___ Other private way
n
Use street name and route #, if applicable.
vehicle.
n
Section H: Witness Information
Be as precise as possible when describing the
Witness Name (Last, First, Middle)
Address
Phone
location.
Section H: Witness Information
n
Provide enough information to locate the crash
n
List all the people who saw the crash but were
to a specific point, not just a street or roadway.
not involved.
Section B: Vehicle You Were Driving
Section I: Property Damage Information
Section I: Property Damage Information (Other than Vehicles)
n
Provide information on your license and the
n
Owner Name (Last, First, Middle)
Address
Phone
Property and Damage Description
Indicate all non-vehicular property that was
vehicle you were driving.
damaged in the crash.
n
Use the codes provided to indicate the cause of
the crash.
Section J: Description of What Happened
n
Describe the crash including events prior to the
Section J: Description of What Happened
Section C: You and Your Passengers
crash for your vehicles and all other vehicles.
n
Provide information on you and your passengers
at the time of the crash.
Section K: Signature
n
Use the codes provided to indicate occupant
n
Please sign and print your name and indicate the
information.
date you completed the form.
Section D: Other Vehicles Involved in the
Where to send completed reports:
Crash
n
Provide information on the other vehicle(s) and
q Mail or deliver one copy to your local police
operator(s) involved in the crash.
department in the city or town where the crash
n
If more than one vehicle involved, please use
occurred.
additional form completing Section D only.
q Mail one copy to your Insurance Company.
Section E: Non-Motorist(s) Involved
q Mail one copy to the RMV at the following
n
Provide information on the non-motorist(s)
address:
Section K: Signature
involved in the crash.
Crash Records
_______________________________________________
Print ________________________________________
Date ___________________________
n
If more than one non-motorist involved, please
Registry of Motor Vehicles
“Signed under Pains and Penalties of Perjury”
use additional form completing Section E only.
P.O. Box 199100
Boston, MA 02119-9100
Page 4
CRA-23 #10365 G003402 05/02 MCI
Page 1