Fillable Commonwealth of Massachusetts Motor Vehicle Crash Operator Report (Town of Stoneham)

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Commonwealth of Massachusetts Motor Vehicle Crash Operator Report (Town of Stoneham)

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Commonwealth of Massachusetts
Motor Vehicle Crash Operator Report
When should I complete a Crash Report?
M.G.L. Chapter 90, Section 26 requires a person who was operating a motor vehicle involved in a crash in which (i) any
person was killed or (ii) injured or (iii) in which there was damage in excess of $1,000 to any one vehicle or other property,
to complete and le a Crash Operator Report with the Registrar within ve (5) days after such crash (unless the person is
physically incapable of doing so due to incapacity). The person completing the report must also send a copy of the report
to the police department having jurisdiction on the way where the crash occurred. If the operator is incapacitated but is not
the vehicle’s owner, the owner is required to le the crash report within the ve (5) days based on his/her knowledge and
information obtained about the crash. The Registrar may require the owner or operator to supplement the report and he/
she can revoke or suspend the license of any person violating any provision of this legal requirement. A police department
is required to accept a report led by an owner or operator whose vehicle has been damaged in a crash in which another
person unlawfully left the scene even if damage to the vehicle does not exceed $1,000.
Mail or deliver one copy to the
local police department or state
police in the city or town where
the crash occurred.
Mail one copy to your
Insurance Company.
Mail one copy to the RMV at
the following address:
Registry of Motor Vehicles
Crash Records
P.O. Box 55889
Boston, MA 02205-5889
How To Complete This Form
Please carefully complete all sections of this form that apply to your crash, circling the answer where appropriate. Illegible
reports will be returned to you.
Where to send completed reports:
Section A: Crash Location
• Provide the city/town where the crash occurred,
the date and time of the crash, and the number of
vehicles involved.
• Complete section A1 or A2.
• Use ocial names of all locations, streets and
landmarks.
• Use street name and route #, if applicable.
• Be as precise as possible when describing the
location.
• Provide enough information to locate the crash to a
specic point, not just a street or roadway.
Section B: Vehicle Yon Were Driving
• Provide information on your license and the vehicle
you were driving.
• Use the codes provided to indicate the cause of the
crash.
Section C: You and Your Passengers
• Provide information on you and your passengers at
the time of the crash.
• Use the codes provided to indicate occupant
information.
Section D: Other Vehicles Involved in the Crash
• Provide information on the other vehicle(s) and
operator(s) involved in the crash.
• If more than one vehicle involved, please use
additional form completing Section D only.
Section E: Non-Motorist(s) Involved
• Provide information on the non-motorist(s) involved in
the crash.
• If more than one non-motorist involved, please use
additional form completing Section E only.
Section F: Crash Conditions
• Use the codes provided to indicate the conditions at
the time of the crash.
Section G: Crash Diagram
• Draw a diagram of how the crash occurred.
• On the diagram, Vehicle 1 represents your vehicle.
Section H: Witness Information
• List all the people who saw the crash but were not
involved.
Section I: Property Damage Information
• Indicate all non-vehicular property that was damaged
in the crash.
Section J: Description of What Happened
• Describe the crash including events prior to the crash
for your vehicles and all other vehicles.
Section K: Signature
• Please sign and print your name and indicate the date
you completed the form.
CRASH102_1119
A. Crash Location
A1. City/Town Where Crash Occurred
1
2
3
4
5
6
7
8
A5. Did the crash occur at an
intersection of two or more streets?
If Yes. If No.
Please complete Section A1 or A2 below to indicate the location of the crash. If you need
additional space to describe the crash location, please use Section J on the last page of this form.
A2. Date of Crash A3. Time of Crash A4. # Vehicles Involved:
Step 1. Please indicate the route or roadway where
you were travelling when the crash occurred:
Step 1. Please indicate the route, roadway and address where the
crash occurred:
Step 2. What was the name (or names) of the intersecting streets?
Step 2. Please provide as much of the following specic location information as possible:
a) Mile Marker number
1 59
2 43
78 6
AM
M
E W
U C
N
B
S
F Unknown
Yes
Yes
Yes
PM
DM
H (Hazardous)
1 Passenger car
2 Light truck (van, mini-van,
pick-up, sport utility)
3 Motorcycle
9 Truck tractor (bobtail)
10 Tractor/semi-trailer
11 Tractor/doubles
12 Tractor/triples
13 Unknown heavy truck
14 Motor home/
recreational vehicle
15 Moped
16 Low Speed
Vehicle
4 Bus (16 or more passengers)
5 Bus (9-15 passengers)
6 Single-unit truck (2 axles)
7 Single-unit truck (3 or more axles)
8 Truck/trailer
3 Turning right
4 Turning left
5 Changing lanes
6 Entering trac lane
7 Leaving trac lane
8 Making U-turn
9 Overtaking/passing
10 Backing
11 Parked
97 Other
99 Unknown
1 Travelling straight ahead
2 Slowing or stopped
T (Doubles/Triples)
S School Bus
N (Tank vehicles)
P (Passenger transport)
Route#
Route#
Route#
Name of Roadway/Street
The crash occurred on Route #:
on the Street/Roadway known as
The crash occurred
(estimate number of feet)
(indicate direction as N/S/E/W)
of:
at Street or Address Number:
Name of Roadway/Street
Name of Roadway/Street
X (Tank and Hazardous)
AX
No
No
No
B. Vehicle You Were Driving
B1. Number of occupants in vehicle (including yourself):
B3. Driver’s License Number
B4. License State B5. DOB B6. Age B7. Sex B8. License Class
B2. Was vehicle damage above $1000?
B20. Full Name of Vehicle Owner (Last, First, Middle)
B24. Was your
Vehicle Towed
from the Scene
Due to Damage?
B10. Vehicle Travel Direction
B11. Your Full Name (Last, First, Middle)
B9. Commercial Driver’s License Endorsements
B21. Street Address
B25. Vehicle Damaged Area (check up to three)
0 None
10 Undercarriage
11 Totaled
B12. Street Address
B13. Insurance Company
B23. 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.
B19. Indicate your type of vehicle
B22. What Was Your Vehicle Doing Prior to the Crash?
B14. Vehicle Registration #
What happened rst?
Collision with Non-Collision
Motor vehicle in trac
Parked motor vehicle
Pedestrian
Cyclist
Animal- deer
Animal- other
Moped
Work zone
maintenance
equipment
Ran o road right
Ran o road left
Cross median/
centerline
Overturn/rollover
Equipment failure
(blown tire, brakes,
etc)
Fire/explosion
Immersion
Second? Third? Fourth?
B15. Reg. Type B16. Reg. State B17. Vehicle Year B18. Vehicle Make
City
City
State
State
Zip Code
Zip Code
Railway vehicle
(train, engine)
Other movable object
Unknown movable
object
Curb
Tree
Utility pole
Light pole or other
post/support
Guardrail
Median barrier
Ditch
Embankment/
Sloping shoulder
Highway trac
signpost
Overhead sign
support
Fence
Mailbox
Crash cushion/
Impact attenuator
Bridge
Bridge overhead
structure
Other xed
object (wall,
building, tunnel)
Unknown xed
object
Jackknife
Cargo/equipment loss
or shift
Separation of units
Downhill runaway
Other non-collision
Unknown non-collision
Other
Unknown
9
jh
10
11
jh
20
21
22
23
jh
24
25
26
27
jh
28
jh
29
jh
30
31
40
41
42
jh
43
44
jh
jh
45
46
47
48
jh
49
50
51
52
97
99
32
jh
33
34
jh
35
jh
jh
36
Route# Name of
Roadway/Street
OR: d) Landmark
OR: c) Intersecting
Street/Roadway
OR: b) Exit Number
97 Other
99 Unknown
17 All terrain
vehicle( ATV)
18 Snowmobile
97 Other
99 Unknown
CRASH102_1119
C. You and Your Passengers
C1. Passenger 1 (Last, First, Middle)
Driver
C5. Passenger 2 (Last, First, Middle)
Passenger 1
C9. Passenger 3 (Last, First, Middle)
Front seat - left side (or
motorcycle driver)
Front seat - middle
Front seat - right side
Second seat - left side (or
motorcycle passenger)
Second seat - middle
Second seat - right side
Third row - left side (or
motorcycle passenger)
1
k
2
3
4
k
5
6
7
0
1
2
3
4
5
97
0
1
2
0
1
k
1
2
1
2
3
k
4
5
97
1
7
8
9
10
None used
Shoulder and lap belt
Lap belt only
Shoulder belt only
Child safety seat
Helmet
Unknown
Deployed-front
Deployed-side
Deployed both front and
side
Not deployed
Not applicable
Unknown
Not ejected
Totally ejected
Partially ejected
Not trapped
Freed by
mechanical
means
Fatal
Suspected serious injury
Suspected minor injury
Possible Injury
No apparent injury
Not transported
EMS
(emergency
service)
Passenger 2
Passenger 3
Seating
Position
Safety
System
Used
Air Bag
Status
Ejected
From
Vehicle?
Trapped?
Injured?
Transported
for Medical
Care?
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 (yourself and all passengers). A
list of the possible codes is provided at the bottom of this section.
C3. DOB
C7. DOB
C11. DOB
C4. Sex
C8. Sex
C12. Sex
Name of Medical
Facility
1 59
2 43
78 6
E WN S
Yes
Yes Yes
H (Hazardous)
5 Changing lanes
6 Entering trac lane
7 Leaving trac lane
8 Making U-turn
9 Overtaking/passing
10 Backing
11 Parked
97 Other
99 Unknown
1 Travelling straight
ahead
2 Slowing or stopped
3 Turning right
4 Turning left
T (Doubles/Triples)
S School Bus
N (Tank vehicles)
P (Passenger transport)
X (Tank and Hazardous)
No
No No
D. Other Vehicle(s) Involved in the Crash
D1. Number of occupants
in the Vehicle:
D2. Number of
injured occupants
D3. Was Vehicle
Damage above $1000?
D4. Moped? D5. Hit and Run?
D23. Full Name of Vehicle Owner (Last, First, Middle)
D13. Vehicle Travel Direction
D14. Name of Vehicle Driver (Last, First, Middle)
D12. Commercial Driver’s License Endorsements
D24. Street Address
D26. Vehicle Damaged Area (check up to three)
0 None
10 Undercarriage
11 Totaled
97 Other
99 Unknown
D15. Street Address
D16. Insurance Company
D25. What Was Your Vehicle Doing Prior to the Crash?
D17. Vehicle Registration # D18. Reg. Type D19. Reg. State D20. Vehicle Year D21. Vehicle Make
City
City
State
State
Zip Code
Zip Code
C2. Address
C6. Address
C10. Address
City
City
City
State
State
State
Zip Code
Zip Code
Zip Code
Seating Position Safety System Used Air Bag Status
Ejected From Vehicle? Trapped?
Transported for Medical Care?Injured?
Third row - middle
Third row - right side
Sleeper section of cab
Enclosed passenger area
Unenclosed passenger area
Trailing unit
Riding on vehicle exterior
Other
Unknown
8
9
10
11
12
13
14
97
99
Police
Other
Unknown
3
97
99
Freed by
non-mechanical
means
Unknown
2
k
d
97
Not
applicable
Unknown
3
k
97
MU C BF Unknown
DM AX
D6. Driver’s License Number
D7. License State D8. DOB D9. Age D10. Sex D11. License Class
1 Passenger car
2 Light truck (van, mini-van,
pick-up, sport utility)
3 Motorcycle
9 Truck tractor (bobtail)
10 Tractor/semi-trailer
11 Tractor/doubles
12 Tractor/triples
13 Unknown heavy truck
14 Motor home/
recreational vehicle
15 Moped
16 Low Speed
Vehicle
4 Bus (16 or more passengers)
5 Bus (9-15 passengers)
6 Single-unit truck (2 axles)
7 Single-unit truck (3 or more axles)
8 Truck/trailer
D22. Indicate your type of vehicle
17 All terrain
vehicle( ATV)
18 Snowmobile
97 Other
99 Unknown
CRASH102_1119
1 Pedestrian 2 Cyclist 3 Skater 97 Other 99 Unknown
E. Non-Motorist(s) Involved in the Crash
F. Crash Conditions
G. Crash Diagram
E1. Indicate the type of non-motorist involved
1
jh
2
jh
3
1
\2
3
4
G
5
G
6
G
1
\2
3
4
99
1
\2
3
4
G
5
1
\2
3
4
5
6
1
\2
3
4
5
G
G
6
1
\2
3
4
5
6
7
8
99
1
\2
3
4
5
6
7
97
99
0
6
7
jh
E2. What was the non-motorist doing prior to the crash?
F1. Light Conditions
F5. Tracway Description
F6. Manner of Collision
F7. Roadway Intersection Type
F2. Weather Conditions (up to two) F3. Trac Control Device F4. Road Surface
E8. Safety Equipment?
E3. Where was the non-motorist prior to the crash?
E9. Injured?
Entering or crossing
location
Walking, running, or
cycling
Working
Daylight
Dawn
Dusk
Dark - lighted
roadway
Dark - roadway
not lighted
Dark - unknown
roadway lighting
Two-way, not divided
Two-way, divided, unprotected median
Two-way, divided, protected median
One-way, not divided
Unknown
Please draw a diagram of the
roadway or streets where the
crash occurred, indicating the
vehicles involved and direction of
travel using the following symbols:
Direction
= Vehicle 1 (Your Vehicle)
= Vehicle 2
= Pedestrian/Non-motorist
= North
Select one of the following if the
crash did not occur on a public
way:
O-street parking lot
Garage
Mall/shopping center
Other private way
Single vehicle crash
Rear-end
Angle
Sideswipe, same
direction
Sideswipe, opposite
direction
Not at intersection
Four-way intersection
T-intersection
Y-intersection
On ramp
O ramp
Clear
Cloudy
Rain
Snow
Sleet, hail,
freezing
rain
Fog, smog,
smoke
No controls
Stop signs
Trac control signal
Flashing trac control signal
Yield signs
School zone signs
Warning signs
Railroad crossing device
Unknown
Dry
Wet
Snow
Ice
Sand, mud, dirt, oil, gravel
Water (standing, moving)
Slush
Other
Unknown
None used
Helmet
Protective pads
(elbows, knees, etc.)
Pushing vehicle
Approaching or
leaving vehicle
Working on vehicle
Standing
Reective clothing
Lighting
Other
Unknown
4
5
jh
6
7
8
9
10
99
1
jh
2
jh
3
Marked crosswalk
at intersection
At intersection but
no crosswalk
Non-intersection
crosswalk
In roadway
Not in roadway
Median (but not on
shoulder)
Island
Shoulder
Sidewalk
Shared-use
path or trails
Unknown
4
5
6
jh
7
8
9
10
jh
99
Other
Unknown
97
99
E4. Full Name of Non-Motorist (Last, First, Middle)
F8. Was the trac control device
functioning at the time of the crash?
F9. School Bus Related?
Indicate
North by
Arrow
F10. Work Zone Related?
E5. Street Address City State Zip Code
E11. If transported, please indicate Hospital/Medical Facility:
E6. DOB E7. Sex
1
2
Not transported
EMS (emergency
service)
E10. Transported for Medical Care?
Police
Other
Unknown
3
97
99
Yes Yes YesNo No No
Trac circle
Five-point or more
Driveway
Railway grade
crossing
Unknown
7
8
9
10
G
99
Severe
crosswinds
Blowing
sand, snow
Other
Unknown
7
G
8
G
97
99
Other
Unknown
97
99
Head on
Rear to rear
Unknown
6
7
99
1
2
1
7
Fatal
Suspected
serious
injury
Suspected
minor injury
Possible
Injury
8
g
9
CRASH102_1119
No
apparent
injury
10
H1. Witness Name (Last, First, Middle)
I1. Owner Name (Last, First, Middle)
H4. Witness Name (Last, First, Middle)
I5. Owner Name (Last, First, Middle)
H2. Street Address
I2. Street Address
H5. Street Address
I6. Street Address
City
City
State
State
Zip Code
Zip Code
H3. Phone
I3. Phone I4. Property and Damage Description
H6. Phone
I7. Phone I8. Property and Damage Description
H. Witness Information
I. Property Damage Information (Other than Vehicles)
J. Description of What Happened
K. Signature
“Signed under Pains and Penalties of Perjury” Print Date
CRASH102_1119
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Commonwealth of Massachusetts Motor Vehicle Crash Operator Report (Town of Stoneham)

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Completed 16 July 2020

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