KANSAS MOTOR VEHICLE ACCIDENT REPORT CODING MANUAL
KANSAS MOTOR VEHICLE ACCIDENT REPORT CODING MANUAL
KANSAS MOTOR VEHICLE ACCIDENT REPORT CODING MANUAL
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Occupants & Vehicles<br />
KDOT Form 850B Rev. 1-2009<br />
DRIVER & PASSENGER INFORMATION<br />
(record pedestrians on supplemental form 854)<br />
Investigating Officer / Badge No. Local Case No. Page of<br />
B. House 007 Example 15 3 5<br />
TU# VIOLATIONS CHARGED CITATION# TU# VIOLATIONS CHARGED More violations in narrative CITATION#<br />
Unit #<br />
Seat Type<br />
TU<br />
ST<br />
TU<br />
ST<br />
D2<br />
01<br />
01 Rebecca<br />
02/09/1995 Sharon Springs KS 68334<br />
02<br />
07<br />
30 D2 24<br />
Stoddard<br />
Pierce<br />
Louise<br />
Samuel<br />
01 Obadiah<br />
11/21/1939 Sharon Springs KS 68334<br />
TRAFFIC UNIT# (01, 03, N3, X3, etc)<br />
TRAFFIC UNIT#<br />
KS<br />
DRIVER Last Name<br />
DRIVER First Name<br />
K01748736<br />
DP - Illegal drugs ingested<br />
METHOD OF DETERMINATION<br />
(mark all that apply)<br />
ALCOHOL<br />
DRUGS<br />
00 No evidence of impairment<br />
01 Evidential Test (Breath,Blood,etc)<br />
02 Preliminary Breath Test PBT<br />
03 Behavioral<br />
Tests: HGN, walk-and-turn, one leg stand, etc.<br />
04 Passive Alcohol Sensor<br />
(detects alcohol from driver's mouth)<br />
05 Observed<br />
(Odor, staggering, slurred speech, etc)<br />
06 Other (e.g. saliva test)<br />
OFFICER'S OPINION OF APPARENT CONTRIBUTING CIRCUMSTANCES - ENTER AS MANY AS APPLY TO THIS <strong>ACCIDENT</strong> (FACTOR TYPE, TU#, CC CODE)<br />
Middle Name<br />
Date of Birth<br />
MN<br />
DOB<br />
A<br />
L<br />
C<br />
O<br />
H<br />
O<br />
L<br />
DRIVER ADDRESS (Number, Street, Suffix, etc.)<br />
City State Zip<br />
New address?<br />
1212 NW Cottonwood<br />
285 S Taylor AVE<br />
DL State Driver's License Number DL Class Driving for<br />
Employer?<br />
MN<br />
DOB<br />
CP<br />
MC - Medication contributed<br />
IMPAIRMENT TEST<br />
(mark all that apply)<br />
NG - No Test given<br />
TR - Test Refused (Alcohol/Drug)<br />
PT - Prelim Positive Test (PBT)<br />
TG - Evidentiary Test given<br />
RP - Results pending<br />
Evidentiary Breath Eye Fluid<br />
0. 0.<br />
Blood (BAC)<br />
0.<br />
Drug screen result<br />
Other<br />
0.<br />
CDL?<br />
KS<br />
01<br />
New address?<br />
K00579932<br />
(813) 555-1847<br />
(813) 555-0374<br />
02<br />
DP - Illegal drugs ingested<br />
METHOD OF DETERMINATION<br />
(mark all that apply)<br />
ALCOHOL<br />
DRUGS<br />
00 No evidence of impairment<br />
01 Evidential Test (Breath,Blood,etc)<br />
02 Preliminary Breath Test PBT<br />
03 Behavioral<br />
Tests: HGN, walk-and-turn, one leg stand, etc.<br />
04 Passive Alcohol Sensor<br />
(detects alcohol from driver's mouth)<br />
05 Observed<br />
(Odor, staggering, slurred speech, etc)<br />
06 Other (e.g. saliva test)<br />
Personal Phone Number<br />
Work Phone Number<br />
Personal<br />
Work<br />
Personal<br />
Work<br />
Gender<br />
Age<br />
F<br />
M<br />
A<br />
L<br />
C<br />
O<br />
H<br />
O<br />
L<br />
SE Used<br />
Eject/Trap<br />
S<br />
N<br />
S<br />
N<br />
N<br />
N<br />
MC - Medication contributed<br />
IMPAIRMENT TEST<br />
(mark all that apply)<br />
NG - No Test given<br />
TR - Test Refused (Alcohol/Drug)<br />
PT - Prelim Positive Test (PBT)<br />
TG - Evidentiary Test given<br />
RP - Results pending<br />
Evidentiary Breath Eye Fluid<br />
0. 0.<br />
Blood (BAC)<br />
0.<br />
Inj Severity<br />
Eject Path<br />
(02, 04, N2, X4, etc)<br />
DL State Driver's License Number DL Class Driving for<br />
Employer?<br />
Drug screen result<br />
Transpt Unit<br />
Extrication?<br />
DR LICENSE RESTRICT COMPLY COMMERCIAL ENDORSEMENTS<br />
DR LICENSE RESTRICT COMPLY COMMERCIAL ENDORSEMENTS<br />
COMPLY<br />
1 2 3 4<br />
COMPLY<br />
00 Not licensed Restrictions? Y<br />
00 Not licensed Restrictions? Y<br />
1 2 3 4<br />
01 Valid License Driver's Lic Complied?<br />
Z - None<br />
01 Valid License Driver's Lic Complied?<br />
Z - None<br />
02 Suspended Restrictions Y N T - Double/Triple Trailer 02 Suspended Restrictions Y N T - Double/Triple Trailer<br />
03 Revoked<br />
1 B Y P - Passenger Vehicle<br />
03 Revoked<br />
1 B Y P - Passenger Vehicle<br />
04 Expired<br />
N - Tank Vehicle<br />
04 Expired<br />
N - Tank Vehicle<br />
2<br />
05 Cancld or Denied H Y<br />
2<br />
H - Placarded Haz. Material 05 Cancld or Denied<br />
H - Placarded Haz. Material<br />
06 Disqualified 3 J02 Y X - Combination Tank/HazMat 06 Disqualified 3<br />
X - Combination Tank/HazMat<br />
07 Restricted S - School Bus<br />
07 Restricted<br />
S - School Bus<br />
4<br />
4<br />
99 Unknown<br />
U - Unknown<br />
99 Unknown<br />
U - Unknown<br />
SUBSTANCE USE<br />
SUBSTANCE USE<br />
AP - Alcohol ingested<br />
AC - Alcohol contributed<br />
(mark all that apply) DC - Illegal drugs contributed<br />
MP - Medication ingested<br />
AP - Alcohol ingested<br />
AC - Alcohol contributed<br />
(mark all that apply) DC - Illegal drugs contributed<br />
MP - Medication ingested<br />
15<br />
70<br />
C<br />
Other<br />
0.<br />
CDL?<br />
Unit #<br />
Seat Type<br />
TU<br />
ST<br />
TU<br />
02<br />
PASSENGER Last Name<br />
PASSENGER First Name<br />
Pierce<br />
Middle Name<br />
Date of Birth<br />
MN<br />
Montgomery<br />
DOB<br />
PASSENGER ADDRESS (Number, Street, Sfx, etc.)<br />
City State Zip<br />
New address?<br />
785 N Taylor AVE<br />
03 Jeremiah<br />
04/28/1957 Sharon Springs KS 66334<br />
MN<br />
New address?<br />
Personal Phone Number<br />
Work Phone Number<br />
Personal<br />
(813) 555-8998<br />
Work<br />
Personal<br />
Gender<br />
Age<br />
M<br />
53<br />
SE Used<br />
Eject/Trap<br />
S<br />
N<br />
Inj Severity<br />
Eject Path<br />
N<br />
Transpt Unit<br />
Extrication?<br />
ST<br />
DOB<br />
Work<br />
TU<br />
MN<br />
New address?<br />
Personal<br />
ST<br />
DOB<br />
Work<br />
TU<br />
MN<br />
New address?<br />
Personal<br />
ST<br />
DOB<br />
Work<br />
Transport<br />
Unit<br />
EMS Time Notified<br />
Injured taken by:<br />
Transport<br />
Unit<br />
EMS Time Notified<br />
Injured taken by:<br />
EMS Arrived<br />
EMS Time@Hosp<br />
Injured taken to:<br />
EMS Arrived<br />
EMS Time@Hosp<br />
Injured taken to:<br />
Transport Units: A, B, C, ..., N
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