VEHICLE ACCIDENT REPORTING PROCEDURES

1. 2. 3. 4. 5. 6. 7. 8. Render aid or assistance to the injured (Section 321.263, Code of Iowa). Do not admit fault and do not discuss the accident with anyone except Department of Administrative Services, General Services Enterprise - Risk Management or law enforcement authorities. Notify the nearest law enforcement agency immediately if accident involves a fatality, injury, or property damage. If the accident involves another party, please use the attached Information Exchange sheet. Notify your supervisor. During Normal Working Hours: Immediately notify the Department of Administrative Services, General Services Enterprise - Risk Management at 515-281-7703. Complete State of Iowa Vehicle Accident Report (form attached). If the accident results in injury or death of any person, or total property damages to an apparent extent of $1,000 or more, the accident report required by Section 321.266, Code of Iowa, must be filed within 72 hours after accident. (Forms available from Investigating Officer.)

If you have questions, please call 515-281-7703. Code Information

Vehicle Type Codes 01= Passenger Car 02 = Car & Trailer 03 = Panel Truck 04 = Pickup Truck 05 = Pickup & Trailer 06 = Pickup Camper 07 = Straight Truck 08 = Truck Tractor 09 = Truck Tractor/Semi 10 = Double Bottom Truck 11 = Tow Truck/Wrecker 12 = Motor Home 13 = Bus 14 = School Bus 15 = Farm Veh./Equip. 16 = Motorcycle 17 = Bicycle, etc. 18 = Recreation Veh. (ATV, Snowmobile) 19 = Maint./Const. Veh. (Dozer, Graders, Tractors, Etc.) 20 = Train 21 = Other (Describe) 22 = Moped 23 = Multi-Purpose (Sport Utility Van, Minivan) 00 = Unknown

Injury Severity Codes 1 = Fatal 2 = Major injuries (broken bones, severe cuts, head injuries, etc.) 3 = Minor injuries (small cuts, bruises and abrasions) 4 =Possible injuries (no visible injury, but individual complaints of pain or discomfort)

Revised 6/99

ACCIDENT CODES A
LOCATION OF ACCIDENT (Where did first damage or injury event occur) 3 = Median 4 = Roadside 5 = Outside of Ritght of Way 0 = Unknown

LIGHT CONDITIONS 4 = DarknessRoadway Lighted 5 = DarknessRoadway Not Lighted 0 = Unknown

1 = On Roadway 2 = Shoulder

1 =Daylight 2 = Dusk 3 = Dawn

TYPE OF ACCIDENT Collision of Motor Vehicle With: 10 = Pedestrian 14 = Parked Vehicle 11 = Veh. in Traffic 15 = Train 12 = Motorcycle in 16 = Pedalcycle Traffic 17 = Animal 13 = Vehicle in Other 18 = Fixed Object Roadway 19 = Other Object

Non-Collision 01 = Overturned 02 = Jackknifed 03 = Carbon Monoxide 04 = Fire/Explosion 05 = Immersion 06 = Other

WEATHER CONDITIONS (Mark up to two conditions) 4 = Mist 5 = Rain 6 = Sleet/Hail 7= 8= 9= 0= Snow Strong Wind Other Unknown

1 = Clear 2 = Cloudy 3 = Fog

TYPE OF TRAFFICWAY (For each vehicle mark one type) 4 = Four or More Undivided 5 = Four or More Divided 6 = Alley 7 = Driveway 8 = Other (Creeper Lane, etc.) 0 = Unknown

VEHICLE ACTION (For each vehicle mark one action) 09 = Slowing-Stopping 10 = Backing 11 = Stopped for Stop Sign/Signal 12 = Stopped in Traffic Lane 13 = Stalled in Traffic Lane 14 = Properly Parked 15 = Improperly Parked 16 = Other (Explain in Narrative) 17 = Unattended Moving Vehicle 00 = Unknown

01 = Going Straight 02 = Turning Left 03 = Turning Right 04 = Makeng U-Turn 05 = Passing 06 = Changing Lanes 07 = Merging 08 = Parking

1 = One Lane or Ramp 2 = Two Lanes 3 = Thee Lanes

SURFACE CONDITIONS (For each vehicle mark up to two conditions) 4 = Snow 5 = Loose Gravel 6 = Mud 7 = Debris 8 = Other 0 = Unknown

1 = Dry 2 = Wet 3 = Ice

FIXED OBJECT STRUCK (For each vehicle mark one fixed object if needed) 08 = Island or Raised Median 09 = Embankment or Retaining Wall 10 = Fence 11 = Guardrail 12 = Light Pole 13 = Sign Post 14 = Tree or Shrubbery 15 = Utility Pole 16 = Other Pole or Support 17 = Mailbox 18 = Impact Attenuator 19 = Other 00 = Unknown

01 = None 02 = Bridge or Overpass 03 = Underpass or Bridge Support 04 = Building 05 = Culvert 06 = Curb 07 = Ditch

SURFACE TYPE (For each vehicle mark one type) 4 = Dirt 5 = Brick 6 = Steel (Bridge Floor) 7 = Wood (Bridge Floor) 8 = Other 0 = Unknown

1 = Portland Cement Concrete 2 = Asphalt Bituminous 3 = Gravel/Rock

VISION OBSCURED (For each vehicle indicate one code) 08 = Moving Vehicles 09 = Person/Object in or on Vehicle 10 = Blinded By Sun or Headlights 11 = Frosted Windows or Windshield 12 = Blowing Snow 13 = Fog/Smoke/ Dust 14 = Other (Explain in Narrative) 00 = Unknown

ROADWAY GEOMETRICS 1 = Straight, Level 4 = Curve, Level 2 = Straight, Up/ 5 = Curve, Up/ Downgrade Downgrade 3 = Straight, Hillcrest 6 = Curve, Hillcrest 7 = Intersection, Level

8 = Intersection, Up/Downgrade 9 = Intersection, Hillcrest 0 = Unknown

01 = Not Obscured 02 = Trees/Crops 03 = Buildings 04 = Embankment 05 = Sign/Billboard 06 = Hillcrest 07 = Parked Vehicles

CHARACTER OF ROADWAY 12 = Not within Intersection but Intersection Related 13 = Alley Intersection 14 = Other (Intersection) Interchange 21 = Intersection of Ramp and Minor Road 22 = Ramp 23 = On Major Road Between Ramps 24 = On Minor Road Between Ramps 25 = Entrance Ramp at Major Road 26 = Major Road at Exit Ramp 27 = Bridge/Overpass Underpass 28 = Not Within Interchange but InterChange related 29 = Other (Interchange) 00 = Unknown

Not At Intersection 01 = No Special Feature 02 = Bridge/Overpass/ Underpass 03 = Railroad Crossing 04 = Business Drive 05 = Farm/Residential/ Drive 06 = Other (NonIntersecion) Intersecion 11 = Within intersection

O APPARENT DRIVER CONDITION (For each driver mark one condition) 01 = Apparently 05 = Not Feeling Well 09 = Drinking Normal 06 = Under Medication (Impaired) 02 = Physical Defect 07 = Infirmities of Age 10 = Drugs 03 = Fatigued 08 = Drinking (Not 11 = Other (Describe) 04 = Apparently Impaired) 00 = Unknown Asleep
DRIVER/VEHICLE RELATED CONTRIBUTING CIRCUMSTANCES (For each vehicle, mark up to two circumstances which caused or contributed to the accident) 01 = None Apparent 12 = FTYROW, From 25 = Disregarded 02 = Ran Traffic Signal Driveway Warning Signal 03 = Ran Stop Sign 13 = FTYROW, From 26 = Reckless Driving 04 = Passed Stopped Parked Position 27 = Improper Backing School Bus 14 = FTYROW, To 28 = Illegal or Improper 05 = Passing Where Pedestrian Parking Prohibited 15 = FTYROW, Other 29 = Failure to Have 06 = Passing Inter16 = Wrong Way on Control ferred With Other One-Way Road 30 = Failed to Turn On Vehicle 17 = Speed Too Fast Lights 07 = Left of Center For Conditions 31 = Inattentive or DisNot Passing 18 = Exceeding Speed tracted 08 = Failed to Yield Limit 32 = Driver Confused ROW (FTYROW), 19 = Drag Racing 33 = Vision Obscured at Uncontrolled 20 = Improper Turn 34 = Oversized Vehicle Intersection 21 = Improper Lane 35 = Overload Pas09 = FTYROW, From Change senger/Cargo Stop Sign 22 = Following Too Close 36 = Inexperienced 10 = FTYROW, From 23 = No Signal or Driver Yield Sign Improper Signal 37 = Vehicle Defect or 11 = FTYROW, Making 24 = Disregarded RailFaulty Equipment Left Turn road Signal 38 = Other 00 = Unknown *FTYROW means Fail to Yield Right of Way

TRAFFIC CONTROLS (For each vehicle mark one control) 08 = School Stop Sign 09 = Stop Arm on School Bus 10 = Railroad Warning Sign 11 = Railroad Automatic Signal 12 = Railroad Crossing Gate 13 = Police Officer 14 = Other Traffic Director 15 = Other Control 16 = Controls Not Functioning/Not In Place 00 = Unknown

01 = No Controls Present 02 = Traffic Signals 03 = Stop Sign 04 = Yeild Sign 05 = Warning Sign 06 = School Signals 07 = No Passing Zone (Marked)

H LOCALITY 1 = Business District (Central) 2 = Manufacturing District 3 = Residential District

4 = Business District (Outlying) 5 = School/Playground Zone 6 = Recreational Area

7 = Open Country (Rural) 8 = Other 9 = Parking Lot/ Private Property 0 = Unknown

State of Iowa -- Department of Administrative Services

VEHICLE ACCIDENT REPORT

TIME AND LOCATION OF ACCIDENT Day of Week Accident Date (Mo/Day/Year) County Road No. Mile Post # Miles State North South West East of
(City/Town and State)

Do Not Write In This Box File No.

Report: This report is to be completed by the driver of the department vehicle. Distribution: Original to Department of Administrative Services within 72 hours of the accident. One copy to the drivers department headquarters. NOTICE: Follow Vehicle Accident Reporting Procedures.

Time

A.M. P.M.

Number of Vehicles

NO. 1 (STATE VEHICLE) Drivers Name (Last, First, MI) Drivers License No./ State Date of Birth License Plate No. State of Registration Male Department Female VIN Vehicle Type Code

Work Street Address Work City/ State/ Zip Work Phone ( ) Vehicle Year/ Make/ Model # of Occupants Leased Vehicle Yes No Home Phone ( )

(Company)

Damage Estimate ($) Description of Damage

NO. 2 (OTHER VEHICLE) If more than two vehicles - use additional forms Home Street Address Drivers Name (Last, First, MI) Home Phone Home City/ State/ Zip ( ) Date of Birth # of Occupants Vehicle Type Code Vehicle Year/ Make/ Model/Mileage Male Work Phone ( ) Female Insurance Company Name/Agents Name Owners Name, Address and Phone License Plate No. Address and Phone Drivers License No./ State State of Registration Damage Estimate ($) Description of Damage

PROPERTY DAMAGED OTHER THAN VEHICLE (Fence, utility pole, etc.) Property Damage Owners Name, Address and Phone INJURED PERSONS (Attach additional sheets if necessary) Name and Address Vehicle No. 1 (State Vehicle) Vehicle No. 2

Describe Injuries

Age

Sex

Injury Code

UNINJURED PASSENGERS IN YOUR VEHICLE Address and Phone Name

WITNESS Name

Address and Phone Revised 8/00

ACCIDENT INFORMATION
A H

Head On Glass Only

B I

Sideswipe Vandalism

Right Angle
J

Mowing Incident
K

Sanding Incident

Legal Intervention

Snow Blower Incident Right Left

Rear End or

F1 You

hit

F2 You were hit

Did you signal a turn?

Yes No

If yes, by Signal Light Hand Signal

Which Direction?

Was your seatbelt fastened? Yes Speed before accident: No Fixed Object Struck Locality
M I

Yes No

Yes Were safety warning lights burning? No ACCIDENT CODES (Description on attached code sheet) Were headlights and taillights burning?
A E J N

Location of Accident Roadway Geometrics Weather Conditions Vision Obscured Veh. 1

B F K Veh. 2

Type of Accident Character of Roadway Type of Trafficway

O

C G

Vehicle Action Traffic Controls

L

Veh. 1 Veh. 2 D Veh. 1 Veh. 2 H

Veh. 1 Veh. 2

Light Conditions
Veh. 1 Veh. 2

Veh. 1 Veh. 2

Surface Conditions
P

Veh. 1 Veh. 2

Surface Type
Veh. 1 Veh. 2

Apparent Driver Condition

Veh. 1 Veh. 2

Driver/Vehicle Contributing Circumstances

ACCIDENT DIAGRAM Description of Accident

Complete Diagram Below

INVESTIGATING OFFICER Name Were charges filed? Yes

Badge # No If yes, against whom?

Department/Agency/Address

Describe Violation (attach copy if you were charged)

SIGNATURES Signed: ______________________________________ Driver Social Security Number: __________________________ Signed: ______________________________________ Drivers Supervisor/Department Head Revised 6/99

State of Iowa -- Department of Administrative Services ACCIDENT INFORMATION EXCHANGE SHEET

State Employee: Please complete the bottom half of this form and give to the other party. Have the other party complete the top half of this form and give it to you.

Other Vehicle Information

Drivers Name _____________________________________________________________________________________ Street Address ____________________________________________ Driver License No./State _____________________________________ Work Phone No. ___________________________________________ City, State, Zip ____________________ Date of Birth _____________________ Home Phone No. __________________

Owners Name _____________________________________________________________________________________ Street Address ____________________________________________ Name of Insurance Company _________________________________ Address of Insurance Company _______________________________ Type of Vehicle (Pass. Car, Truck, etc.) ______________________________ Make _______________________ Number of Occupants Year _________________ City, State, Zip ____________________ Policy No. _______________________ City, State, Zip ____________________ Mileage _________________________ License Plate No. _________________

___________________________________________________________________________

Names and Addresses of Passengers:

Cut Along Dotted Line

State Employee
Name __________________________________________________ Home Address___________________________________________ Driver License No./State____________________________________ Type of Vehicle (Pass. Car, Truck, etc.)__________________________ Make/Model _________________ Year _________________ Work Phone ______________________ City, State, Zip ____________________ Date of Birth _____________________ Mileage _________________________ License Plate No. _________________

Owners Name _____________________________________________________________________________________ Street Address ____________________________________________ City, State, Zip ____________________

This is to advise, the State of Iowa is self-insured. If you have any questions, please contact: Department of Administrative Services General Services Enterprise - Risk Management 515-281-7703

Revised 11/03