"'A. Pre-Collision Vehicle Action1 Avoiding Object in Roadway2 Backing3 Changing Lanes4 Entering Parked Position5 Going Straight Ahead6 LeavingTraffICLane7 Making Left Turn8 Making RightTurn9 Making U Turn

10 Merging11 Overtaking12 Parked13 Slowing or Stopping14 Starting From Part<ing15 StartinginTraffic16 Stopped in Traffic17 WrongWay97 Other98 UnknownB. Unit Type Code1 Bicycle2 Bus3 EmergencyVehicle-In Response4 EmergencyVehicle-Non-Response5 FarmTractor andlor Farm Equipment6 Go-Cart7 H. & RunlUnknown8 Lt.Trud<(Van. Sports UtiIKy,Pick-up)9 MiIKaryVehicle

10 Motorcycle11 Motor Horne/RecreationalVehicle12 Motor Scooter or Motor Bicycle13 Other Public 0Nned Vehicle14 Passenger Car15 Passenger Car & Trailer16~17 RailroadTrain18 Riding Animal/Animal-Drawn Vehicle19 School Bus20 Taxicab21 Truci<&Trailer22 Truci<--Single UM23 Truci<Tractor & Sami-Trailer24 Truci<--Other Combination97 Other

C. Fire1 Yes2 No

D. Overturned1 Yes2 No

E. Contributing Factors-Human1 AlcohollnvoMlment2 Cell Phone3 DisregardTraffic Control4 Distraction5 Drug Involvement6 Emotional7 Exceeded Stated Speed Limit8 Failedto Yield Right of Way9 Fatigue

10 Fell Asleep11 FollowingToo Close12 Improper Backing13 Improper Passing14 Inattention15 Lost ConsciousnesslFainted16 Medication17 Misjudge Clearance18 NotUnder Proper Cootrol19 (}.oercorrectinglCNersteering20 PflysicaJDisability21 Sick22 Too Fast for Conditions23 Turning Improperly24 Weaving In Traffic97 Other99 None Detected

KENTUCKY UNIFORM POLICETRAFFIC COLLISION REPORT

F. 1st & 2nd Event Collisio~Non-Fixed Obiect

Animal 1Bicycle 2

Deer 3Motor Vehicle in Transport. Other Roadway 4

Other Motor Vehicle 5Pedestrian 6

Railroad Train 7Other ObjecVNot Ftxed 8

G. Fixed ObiectBridge Parapet End 9

Bridge Pier. Abutment 10Bridge Rail 11

BuildingIWail 12Crash Cushionllmpact Attenuator 13

CulvertlHead Wall 14Curbing 15

Earth EmbankmentJRoci<CuVO'ch 16Fence 17

Fire Hydrant 18Guardrail End 19

Guardrail Face 20LighVLuminaire Support 21

Mailbox 22Median Barrier 23

Other Post, Pole or Support 24Overhead Sign Support 25

Sign Post 26Snow Embankment 27

TollBooth 28Traffic Signal Support 29

Tree 30UtiIKy Pole 31

Other FtxedObject 32H. Non-Collision

Fell From Vehicle 33FtreJExplosion 34

Jaci<kn~e 35Overturned 36

Ran Off Roadway (Only) 37Submersion 38

Other Non-Collision 39I. Contributing Factors-Vehicutar

Brakes Defective 1Headlights Defective 2

Load Securement 3Other Lighting Defective 4

Oversized Load On Vehicle 5Overweight 6

Steering Failure 7Tire Failure 8

Tow Hitch Defective/Sap. of Units 9Other 97

None Detected 99J. Contributing Factors-Environmental

Animals Action 1Construction War!<Zone 2

Debris in Roadway 3Fixed Object(s) 4

Glare 5HoIesIDeep RutslBumps 6

Improperly Parl<edVehicle(s) 7ImproperlNon-Wort<ingTraffICCootrols 8

MaintenancelUtilKy Work Zone 9Shoulders DelectivelDrop-off 10

Slippery Surface 11V_ Obstructedllimited 12

Water Pooling 13Other 97

None Detected 99K. Underride/Override

No Underride Of Override 1Override. Motor Vehicle in Transport 2

Override. Other Vehicle 3Underride (Compartment Intrusion) 4

Underride (Compt.lntrusion Unknown) 5Underride (No Compartment Intrusion) 6

Unknown 98

IMPORTANT INSTRUCTIONS:1. Use a black or blue ballpoint pen to completely fill in

the appropriate ovals along the sides and body ofthe Traffic Collision Report. PENCILS, MARKERS,FELT-TIP,OR OTHER COLOR PENS ARE NOTACCEPTABLE.

Correct Way: 0

Wrong Way: 00

A minimum amount of "white-out" is acceptable tocorrect errors.

2. Using the front of the Cover Code Sheet, fill in thecorrect corresponding ovals located down bothsides of the Unit Pages of the Traffic CollisionReport. This information pertains to each unitinvolved in the traffic collision.

3. The back of the Cover Code Sheet identifies theinformation needed to correctly answer items14-23 also on the Unit Pages of the TrafficCollision Report. This information pertains to"individuals" involved in the traffic collision.

4. Use upper case block letters to fill in textinformation.

5. There are separate supplemental reports in theback of each report pad.

6. See the Traffic Collision Manual for procedures onsubmitting a supplemental traffic collision report.

Manner of Collision Legend:*

(roadway I"t ••.• ectlon only)

"Front of Car ~

3

6

2 Head On1 Backing

++----

Angle

+----. t---+5 Rear to RearOpposing Left Turn 4 Rear End

----.( +------4) f--(-----+

Sideswipe, Opposite 7 Sideswipe, SameDirection Direction

8

Sample

COLOR CODE 18 Location of InjuryOrange-Required (Most Severe)

1 Head/FaceRed-Fatal

Gray-Injury Only 2 Neck

Blue-Commercial Vehicle 3 Chest

14 Person Type 4 Backf..--- 5 Abdomen/Pelvis1 Driver

Arms/Hands62 Passenger7 Legs/FeetPedestrian38 Multiple-Entire Body4 Animal-Drawn/Ridden

19 Restraint Use5 Bicyclist1 Shoulder/Lap Belt6 Train Engineer2 Installed/Not In Use..

7 Witness3 Lap Belt Only

8 Owner 4 Shoulder Belt Only15 Transport to Medical Facility 5 Child Safety Seat

(y) Yes 6 Helmet7 Helmet Not Used® No8 Other Passive Restraint16 Position IniOn Vehicle9 Not Installed

10 10 Child Booster Seat

L. 20 Air Bag

Installed/Not Deployed11 2 3Deployed-Front10 210 4 5 6Deployed-Side37 8 9Not Installed411

21 Trapped121 Not Trapped

t 13 t 2 Extricated By Mechanical Means

3 Freed By Non-Mechanical Means1 Driver 22 Ejection From Vehicle-2-9 Passenger 1 Not Ejected

10 Riding/Hanging On Outside 2 Partially Ejected11 Sleeper Compartment 3 Totally Ejected12 Pickup Bed Ejection Path13 Trailer 23 (Fatal Only)

1 Not Ejected/Not Applicable17 Injury Severity2 Through Side Door Opening

1 Fatal 3 Through Side Window2 Incapacitati ng 4 Through Windshield3 Non-Incapacitating 5 Through Back Window4 Possible Injury 6 Through Back Door5 None Detected 7 Tailgate Opening

8 Through Roof Opening

(sunroof, convertible top down)

9 Through Roof

10 Other Path (e.g., back of pickup truck)

11 UnknownNCS Pearson™ forms EM-203974-5:654321 GS03 Printed m U.S.A.

Sample