Administration of Justice

El Camino College

Professor Ray Lewis

TRAFFIC COLLISION REPORT

SPECIAL CONDITIONS: / NUMBER INJURED: / HIT & RUN FELONY: / CITY: / JUDICIAL DISTRICT: / NUMBER:
NUMBER KILLED: / HIT & RUN MISD / COUNTY: / REPORTING DISTRICT: / SEAT:
COLLISION OCCURRED ON: / DATE: / TIME: (24:00) / NCIC # / OFFICER ID:
MILEPOST INFORMATION: / DAY OF THE WEEK:
SundayMondayTuesdayWednesdayThursdayFridaySaturday / TOW AWAY
YES NO / PHOTOGRAPHS BY:
NONE
AT INTERSECTION WITH
OR FEETMILES OF / STATE HWY REL
YES NO
PARTY 1 / DRIVERS LICENSE NO. / STATE: / CLASS: / SAFETY EQUIP / VEH YR. / MAKE/MODEL/COLOR / LICENSE NO. / STATE
DRIVER / NAME (First, Middle, Last)
PED. / STREET ADDRESS: / OWNERS NAME: / SAME AS DRIVER
PARKED VEH / CITY/STATE/ZIP / OWNERS ADDRESS: / SAME AS DRIVER
BICYCL-IST / SEX
MF / HAIR / EYES / HEIGHT / WEIGHT / DOB / RACE / DISPOSITION OF VEHICLE ON ORDERS OF:
OFFICER DRIVER OTHER
OTHER / HOME PHONE: / BUSINESS PHONE / PRIOR MECHANICAL DEFECT:
NONE APPARENT REFER TO NARRATIVE
CHP USE ONLY
VEHICLE TYPE / DESCRIBE VEHICLE DAMAGE
UNKNOWNNONEMINORMODERATEMAJORTOTAL / SHADE DAMAGED AREA
INSURANCE CARRIER: / POLICY NUMBER:
DIR OF TRAVEL / ON STREET OR HIGHWAY / SPEED LIMIT / PCF / ICC
PUC
CHP
PARTY 2 / DRIVERS LICENSE NO. / STATE: / CLASS: / SAFETY EQUIP / VEH YR. / MAKE/MODEL/COLOR / LICENSE NO. / STATE
DRIVER / NAME (First, Middle, Last)
PED. / STREET ADDRESS: / OWNERS NAME: / SAME AS DRIVER
PARKED VEH / CITY/STATE/ZIP / OWNERS ADDRESS: / SAME AS DRIVER
BICYCL-IST / SEX
MF / HAIR / EYES / HEIGHT / WEIGHT / DOB / RACE / DISPOSITION OF VEHICLE ON ORDERS OF:
OFFICER DRIVER OTHER
OTHER / HOME PHONE: / BUSINESS PHONE / PRIOR MECHANICAL DEFECT:
NONE APPARENT REFER TO NARRATIVE
CHP USE ONLY
VEHICLE TYPE / DESCRIBE VEHICLE DAMAGE
UNKNOWNNONEMINORMODERATEMAJORTOTAL / SHADE DAMAGED AREA
INSURANCE CARRIER: / POLICY NUMBER:
DIR OF TRAVEL / ON STREET OR HIGHWAY / SPEED LIMIT / PCF / ICC
PUC
CHP
PARTY 3 / DRIVERS LICENSE NO. / STATE: / CLASS: / SAFETY EQUIP / VEH YR. / MAKE/MODEL/COLOR / LICENSE NO. / STATE
DRIVER / NAME (First, Middle, Last)
PED. / STREET ADDRESS: / OWNERS NAME: / SAME AS DRIVER
PARKED VEH / CITY/STATE/ZIP / OWNERS ADDRESS: / SAME AS DRIVER
BICYCL-IST / SEX
MF / HAIR / EYES / HEIGHT / WEIGHT / DOB / RACE / DISPOSITION OF VEHICLE ON ORDERS OF:
OFFICER DRIVER OTHER
OTHER / HOME PHONE: / BUSINESS PHONE / PRIOR MECHANICAL DEFECT:
NONE APPARENT REFER TO NARRATIVE
CHP USE ONLY
VEHICLE TYPE / DESCRIBE VEHICLE DAMAGE
UNKNOWNNONEMINORMODERATEMAJORTOTAL / SHADE DAMAGED AREA
INSURANCE CARRIER: / POLICY NUMBER:
DIR OF TRAVEL / ON STREET OR HIGHWAY / SPEED LIMIT / PCF / ICC
PUC
CHP
PREPARER’S NAME: / REVIEWER’S NAME: / DATE REVIEWED:

TRAFFIC COLLISION CODING

DATE OF COLLISION: / TIME: / NCIC NUMBER: / OFFICER I.D. / NUMBER:
PROPERTY
DAMAGE / OWNERS NAME/ADDRESS: / NOTIFIED
YES NO
DESCRIPTION OF DAMAGE:
SEATING POSITION / SAFETY EQUIPMENT / EJECTED FROM VEH.



1 - Driver2 to 6 - Passengers7 - Stationwagon Rear8 - RR. OCC. TRK or Van9 - Position Unknown0 - Other /

OCCUPANTS

/ Air bag deployed / M/C BICYCLE–HELMET
None in Vehicle / Air bag not deployed / Not ejected
Unknown / Other / Driver / Fully ejected
Lap Belt Used / Not Required / No / Partially ejected
Shoulder Harness Used /

CHILD RESTRAINT

/ Yes / Unknown
Shoulder Harness Not Used / In vehicle used
Lap/Shoulder Harness Used / In vehicle not used / Passenger
Lap/Shoulder Harness Not Used / In vehicle use unknown / No
Passive Restraint Used / In vehicle improper use / Yes
Passive Restraint Not Used / None in vehicle
ITEMS MARKED BELOW WHICH ARE FOLLOWED BY AN ASTERISK (*) SHOULD BE EXPLAINED IN THE NARRATIVE.
PRIMARY COLLISION FACTOR LIST NUMBER OF PARTY AT FAULT / TRAFFIC CONTROL DEVICES / 1 / 2 / 3 / TYPE OF VEHICLE / 1 / 2 / 3 / MOVEMENT PROCEDING COLLISION
1234567890 / VC Section Violated Cited
Yes
No / Controls functioning / Passenger car/Station wagon / Stopped
Controls not functioning* / Passenger car with trailer / Proceeding Straight
Controls obscured / Motorcycle/Scooter / Ran Off Road
1234567890 / Other Improper Driving / No controls present/factor* / Pickup or panel truck / Making Right Turn
Other Than Driver / TYPE OF COLLISION / Pickup/Panel truck with trailer / MAKING LEFT TURN
Unknown * / Head-on / Truck or Truck tractor / Making U Turn
1234567890 / Fell Asleep * / Sideswipe / Truck/Truck tractor with trailer / Backing
Rear End / School bus / Slowing/Stopping
WEATHER (Mark 1 to 2 items) / Broadside / Other Bus / Passing Other Vehicle
Clear / Hit Object / Emergency Vehicle / Changing Lanes
Cloudy / Overturned / Hwy. Const. Equipment / Parking Maneuver
Raining / Vehicle/Pedestrian / Bicycle / Entering Traffic
Snowing / Other: / Other Vehicle / Other Unsafe Turning
Fog/Visibility ft / MOTOR VEHICLE INVOLVED WITH / Pedestrian / Xing Onto Opposite Lane
Other: / Non-collision / Moped / Parked
Wind / Pedestrian / Merging
Other Motor Vehicle / OTHER ASSOCITED FACTOR (Mark 1 to 2 items) / TRAVELING WRONG WAY
LIGHTING / Motor Veh. on other roadway / VC Section Violation:Cited
Yes
No / OTHER:
Daylight / Parked motor vehicle
Dusk/Dawn / Train
Dark – Street Lights / Bicycle / VC Section Violation:Cited
Yes
No
Dark – No Street Lights / Animal:
Dark – Street Lights no functioning / Fixed Object:
Other Object: / VC Section Violation:Cited
Yes
No / SOBRIETY – DRUG PHYSICAL (Mark 1 to 2 items)
Had Not Been Drinking
ROADWAY SURFACE / Vision Obscurement / HSD – UNDER INFLUENCE
Dry / Inattention / Hsd – Not Under Unflu. *
Wet / Stop and GoTraffic / Hsd – Impairment Unk.*
Snowy – Icy / Entering/Leaving ramp / Under Drug Influ.*
Slippery (muddy, Oily, etc.) / Previous collision / Impairment – Physical *
Unfamiliar with road / Impairment Not Known
ROADWAY CONDITIONS
(Mark 1 to 2 items) / Defective Veh. EquipCited
Yes
No / NOT APPLICABLE
SLEEPY / FATIGUED
Holes, deep ruts* / PEDESTRIANS ACTION
Loose material on Rdwy* / No pedestrian involved / Uninvolved vehicle / SPECIAL INFORMATION
Obstruction on Rdwy* / Crossing in Crosswalk at intersection / Other: / Hazardous Material
Construction – Repair zone / None Apparent
Reduced Roadway width / Crossing – not a crosswalk / Runaway Vehicle
Flooded* / In Road – Includes Shoulder
Other* / Not in Road
No unusual conditions / Approach/Leaving School Bus
SKETCH / MISCELLANEOUS