Officer Incident Report For:

Mail To: ATV – Snowmobile Admin

Bureau of Law EnforcementF. WardenOn Scene Investigation

Department of Natural ResourcesW. SupervisorPost Incident Investigation

PO Box 7921Rec. Safety Warden

Madison, WI53707-7921Form 4100-203 (Rev. 11/04)

Instructions to Officers: Complete all portions of this report. For the purpose of this report, fatal snowmobile and ATV incidents, along with all reportable two-party incidents, shall be investigated. Reportable being injury incidents which require a physician’s attention. Two-party incidents are those with two or more machines involved, or one machine and a person not on a snowmobile/ATV. Other snowmobile/ATV incidents may be investigated as time permits.

Report Number

Crash inCIDENT CRITERIA

Number of Vehicles in crash: Death related to incident? Yes No

Injuries requiring medical treatment? Yes NoDisappearance of person indicating injury or death? Yes No

Date of Incident

/

Day of Week

/

Time of Day

AM PM / Location of Incident:
Private Land Public Road Public TrailLake or Stream
Public Land Hwy. Right-of-way Private Trail Route
County: /

City or Township:

/

State: WI

OPERATOR A

Operator’s Name Telephone Number

() -

Address

City, State, Zip Code

,
Operator’s Date of Birth (M-D-Y)--

Age Gender Male Female

/ Owner’s Name (if different than operator)Telephone Number
() -

Address

City, State, Zip Code

,
Operator Completed DNR Snowmobile/ATV Safety Training Course? Yes No /

Operator’s Experience

0 – 100 Hours Over 100 Hours

Was the Operator Wearing A Helmet?

Yes No /

Operator Factor

Appeared Normal Ability Impaired

Did the Operator Have Eye Protection?

Yes No /

Operator’s Condition

Had Been Drinking Physical Disability
Using Drugs Other

Blood Alcohol Test

Intoxilyzer Blood Results No

Operator Cited For OWI?

Yes No /

Statement Taken?

Yes No / Comments:

OPERATOR B

Operator’s Name Telephone Number

() -

Address

City, State, Zip Code

,
Operator’s Date of Birth (M-D-Y)--
AgeGender Male Female /

Owner’s Name (if different than operator) Telephone Number

() -

Address

City, State, Zip Code

,

Operator Completed DNR Snowmobile/ATV Safety Training Course? Yes No

/

Operator’s Experience

0 – 100 Hours Over 100 Hours

Was the Operator Wearing A Helmet?

Yes No /

Operator Factor

Appeared Normal Ability Impaired

Did the Operator Have Eye Protection?

Yes No /

Operator’s Condition

Had Been Drinking Physical Disability
Using Drugs Other

Blood Alcohol Test

Intoxilyzer Blood Results No

Operator Cited For OWI?

Yes No /

Statement Taken?

Yes No / Comments:

Officer Incident Report For:

VEHICLE A

Vehicle Type

Snowmobile Three Wheel ATV Four Wheel ATV

/

Name of Passenger – Vehicle A

/

Telephone Number

() -

Vehicle Rented

Yes No

/

Vehicle Borrowed

Yes No /

Address

Make of Vehicle

/

Chassis Serial Number

/

City, State, Zip Code

,

Vehicle Registration Number

/

Expiration Date

/

State

/ Date of Birth (M-D-Y)
-- /

Age

/

Gender Male Female

Model of Vehicle

/

Year

/

CC/Horsepower

/

Was Passenger Wearing A Helmet?

Yes No

Studded Tracks

Yes No /

Estimated Speed At Time of Incident MPH

/

Did Passenger Have Eye Protection?

Yes No

VEHICLE B

Vehicle Type

Snowmobile Three Wheel ATV Four Wheel ATV

/

Name of Passenger – Vehicle A

/

Telephone Number

() -

Vehicle Rented

Yes No

/

Vehicle Borrowed

Yes No /

Address

Make of Vehicle

/

Chassis Serial Number

/

City, State, Zip Code

,

Vehicle Registration Number

/

Expiration Date

/

State

/ Date of Birth (M-D-Y)
-- /

Age

/

Gender Male Female

Model of Vehicle

/

Year

/

CC/Horsepower

/

Was Passenger Wearing A Helmet?

Yes No

Studded Tracks

Yes No /

Estimated Speed At Time of Incident MPH

/

Did Passenger Have Eye Protection?

Yes No

TYPE AND CAUSE OF INCIDENT

/

ENVIRONMENT

Type Of Incident

Fell from moving Snowmobile/ATV
Collision with fixed object
Collision with another Snowmobile/ATV
Collision with moving motor vehicle
Collision with parked motor vehicle
Broke through ice
Driven into open water
Snowmobile/ATV rolled over
Struck fence or cable
Injured by contact with part of Snowmobile/ATV
Pedestrian struck by Snowmobile/ATV
Being pulled by Snowmobile/ATV
Other: /

Activity at Time Of Incident

Recreational
Farm related
Sanctioned race/event
Construction
Hunting

What in Your Opinion Contributed to the Incident?

Drinking or Drugs
Vehicle speed
Equipment failure
Failure to yield
Inexperience
Trail conditions
Other: /

Weather

Foggy – Mist
Raining
Snowing
Clear

Temperature

˚ F

Trail Condition

Icy
Smooth
Rough
Muddy
Dry
Other: /

Visibility

Good
Fair
Poor
Day
Night

Road Condition

Dry
Snow Covered
Wet
Gravel
Paved
Other:

DESCRIBE WHAT HAPPENED (The Sequence of Events Leading Up to the Incident):

Officer Incident Report For:

Page 1 of 4

Diagram area of damage on appropriate chart below.

Thrust Direction At Point of Greatest Impact / Area Of Damage

Snowmobile-A

Snowmobile-B

ATV-B

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ATV-B

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INJURIES/DEATHS

Vehicle (Circle One)A B

Name:
Address:
City, State, Zip Code:
Telephone Number:() -
Date of Birth & Age:
Was The Victim:
Operator Passenger Pedestrian
Type of Injury: Minor – No Permanent Injury
Major – Required Hospitalization
Fatal
Specific Injury: (If more than one, number choices in order of severity)
Amputation Laceration
Broken Bone(s) Spinal Injury
Burns Sprain/Strain
Contusion Neck Injury
Head Injury Back Injury
Hypothermia Shock
Internal Injuries Dislocation
Cause Of Death:
Trauma/Impact Injury
Drowning
Hypothermia
Other /

A B

() -
Operator Passenger Pedestrian
Minor – No Permanent Injury
Major – Required Hospitalization
Fatal
Amputation Laceration
Broken Bone(s) Spinal Injury
Burns Sprain/Strain
Contusion Neck Injury
Head Injury Back Injury
Hypothermia Shock
Internal Injuries Dislocation
Trauma/Impact Injury
Drowning
Hypothermia
Other /

A B

() -
Operator Passenger Pedestrian
Minor – No Permanent Injury
Major – Required Hospitalization
Fatal
Amputation Laceration
Broken Bone(s) Spinal Injury
Burns Sprain/Strain
Contusion Neck Injury
Head Injury Back Injury
Hypothermia Shock
Internal Injuries Dislocation
Trauma/Impact Injury
Drowning
Hypothermia
Other
WITNESSES(Other Than Operator or Injured Persons)
Name:
Address:
City, State, Zip:
Telephone #:() -
Date Of Birth: / () - / () -
INFORMATION SOURCES

Other Investigating

Agencies:

Other Agencies

Rendering Assistance:

Attatch All Case Activity Reports And Diagrams

Attachments To This Report:

Narrative/Case Activity Report Coroner’s Report Statements Other:
Diagram Of Incident Citation Or Criminal Complaint Photographs/Negatives
BAC Report Other Agency ReportsWere Photos Taken? Yes No By Whom?

Enforcement Action Taken (Please Attach Copy Of Citation Or Complaint)

Yes No If Yes Explain:

Validation

Investigation Prepared By:

/ Date: /

Agency:

Primary Cause Of Incident

/

Secondary Cause Of Incident:

/

Causes Based On:

Invest. & Oper. Report Investigation Other

REVIEWER

Reviewed By (Supervisor)

/ Date: / Agency:

 ATTACH ALL CASE ACTIVITY REPORTS AND DIAGRAMS 

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