Fill and Sign the Ohsu Transcript Request Form

Colorado State Patrol Instructions for completing a counter crash report This reporting procedure cannot be used for any crash involving loss of human life, injuries which are evident at the scene, drugs, or alcohol use.* Print the information using blue or black ink. You have been provided with a template and a blank report. Fill in the information on the blank form (you may make as many copies as you need); do not fill in the shaded areas -- complete only those numbered areas indicated below: 1. Date and time of your crash. 2. City (if applicable) and County in which the crash occurred. 3. Today’s date. 4. Total vehicles involved in the crash, including your vehicle. 5. Place an “X” in this box if public property (a road sign, utility pole, etc.) was involved or if the accident occurred at a railroad crossing, in a construction zone, or on a bridge. 6. Enter the road on which the crash occurred, approximated distance (feet or miles) from the nearest town, intersection, road, street, or milepost. If it occurred at an intersection, first enter the road you were traveling on, then the intersecting road. 7. You are vehicle #1, the other driver is vehicle #2, 3, etc. If any of the vehicles were parked or a bicycle or pedestrian was involved, place an “X” by the word “Parked”, “Bicycle”, or “Pedestrian”, as appropriate. 8. Fill out as much information as you have for all parties involved. 9. Vehicle information. Year, make, model, etc. If you are the driver as well as the owner, leave this portion blank for the vehicle owner. 10. The front of the vehicle points to the left of the page. Using the damage severity codes (1=slight, 2=moderate, 3=extreme), enter a 1, 2, or 3 in the area of the car diagram that corresponds to the damage each vehicle received as a result of this crash. 11. Provide complete insurance information for your vehicle and provide all the insurance information available to you on the other vehicle(s) involved. 12. Enter the owner of any property, other than a vehicle, that was damaged in the crash (e.g., lawn, fence, mailbox, horse, etc.). 13. Describe the crash in your own words. Refer to yourself as Vehicle #1, and the other party/parties as Vehicle #2, Vehicle #3, etc. You may draw a diagram if you wish, but it is not necessary. 14. Sign the report and send it in to the address at the top right of the form or drop it off at your nearest Colorado State Patrol office. * Law enforcement must be notified immediately whenever a crash involves drugs, alcohol, injuries, or the loss of human life. STATE OF COLORADO TRAFFIC ACCIDENT REPORT MAIL TO: State of Colorado Motor Vehicle Division Traffic Records Denver, CO 80261-0016 Sheet _____ of _____ sheets DATE OF REPORT DR-447 (REV 2/01) - E DATE /TIME OF ACCIDENT TOTAL VEHICLES VEH #1 OR _____ LAST NAME CITY PUBLIC PROPERTY RAILROAD CROSSING CONSTRUCTION ZONE BRIDGE LOCATION ROUTE, STREET ROAD _____ MILES _____ FEET ________________________________________ BICYCLE# ____PEDESTRIAN# _____ PARKED ____ FIRST MI STREET ADDRESS VEH #1 OR _____ LAST NAME STATE DRIVERS LIC.NUMBER STATE MAKE SEX LIC. PLATE NO. STATE DRIVERS LIC.NUMBER YEAR ZIP STATE MAKE SEX DOB BODY TYPE STATE COLOR VEHICLE ID NO. VEHICLE OWNER LAST NAME FIRST ADDRESS CITY MI STATE FIRST ADDRESS ZIP VEHICLE OWNER LAST NAME MI CITY STATE 1- SLIGHT 2- MODERATE 3 - EXTREME 3 4 5 6 7 18 3 9 17 2 10 15 14 13 12 5 11 6 7 8 9 16 18 19 1 _____ 20 INSURANCE CO. 4 17 19 1 10 15 14 13 12 11 Undercarriage EXP. DATE _____ 20 INSURANCE CO. POLICY NO. ZIP 1-SLIGHT 2-MODERATE 3-EXTREME 8 2 16 OF BUS. PHONE MODEL LIC. PLATE NO. VEHICLE ID NO W RES. PHONE STATE DOB COLOR S AT _____________________________________ CITY BODY TYPE MODEL E STREET ADDRESS BUS. PHONE ZIP N BICYCLE# ____PEDESTRIAN# _____ PARKED ____ FIRST MI RES. PHONE CITY YEAR COUNTY Undercarriage EXP. DATE POLICY NO. OWNER DAMAGED PROP. LAST NAME FIRST ADDRESS CITY MI STATE ZIP OWNER DAMAGED PROP LAST NAME FIRST ADDRESS CITY MI STATE DESCRIBE ACCIDENT Information contained on this report furnished in total by reporting parties. No on-scene investigation. Report filed by: ____________________________________________________________ ZIP STATE OF COLORADO TRAFFIC ACCIDENT REPORT MAIL TO: State of Colorado Motor Vehicle Division Traffic Records Denver, CO 80261-0016 Sheet _____ of _____ sheets DATE OF REPORT DR-447 (REV 2/01) - E DATE /TIME OF ACCIDENT TOTAL VEHICLES VEH #1 OR _____ LAST NAME CITY PUBLIC PROPERTY RAILROAD CROSSING CONSTRUCTION ZONE BRIDGE LOCATION ROUTE, STREET ROAD _____ MILES _____ FEET ________________________________________ BICYCLE# ____PEDESTRIAN# _____ PARKED ____ FIRST MI STREET ADDRESS VEH #1 OR _____ LAST NAME STATE DRIVERS LIC.NUMBER STATE MAKE SEX LIC. PLATE NO. STATE DRIVERS LIC.NUMBER YEAR ZIP STATE MAKE SEX DOB BODY TYPE STATE COLOR VEHICLE ID NO. VEHICLE OWNER LAST NAME FIRST ADDRESS CITY MI STATE FIRST ADDRESS ZIP VEHICLE OWNER LAST NAME MI CITY STATE 1- SLIGHT 2- MODERATE 3 - EXTREME 3 4 5 6 7 18 3 9 17 2 10 15 14 13 12 5 11 6 7 8 9 16 18 19 1 _____ 20 INSURANCE CO. 4 17 19 1 10 15 14 13 12 11 _____ 20 Undercarriage EXP. DATE INSURANCE CO. POLICY NO. ZIP 1-SLIGHT 2-MODERATE 3-EXTREME 8 2 16 OF BUS. PHONE MODEL LIC. PLATE NO. VEHICLE ID NO W RES. PHONE STATE DOB COLOR S AT _____________________________________ CITY BODY TYPE MODEL E STREET ADDRESS BUS. PHONE ZIP N BICYCLE# ____PEDESTRIAN# _____ PARKED ____ FIRST MI RES. PHONE CITY YEAR COUNTY Undercarriage EXP. DATE POLICY NO. OWNER DAMAGED PROP. LAST NAME FIRST ADDRESS CITY MI STATE ZIP OWNER DAMAGED PROP LAST NAME FIRST ADDRESS CITY MI STATE DESCRIBE ACCIDENT Information contained on this report furnished in total by reporting parties. No on-scene investigation. Report filed by: ____________________________________________________________ ZIP