Agency Number

STATE OF MISSISSIPPI UNIFORM CRASH REPORT

Agency Case Number

0 1

Page

Agency Name

G2. Status Code

C

G5. Officer Time G3. Reported Date (MM/DD/YYYY)

/

G4. Reported Time (2400)

F

.

N

G15. Direction

M

N

E

S

W

G16. Intersecting Street Name

G19. Latitude

Crash with OMV in road:

G8. Injured

G12. Trafficflow Direction

W

.

Fixed Object

Non-Crash in Road

None

City Street

Rear end turn

Jackknife

Embankment/Ditch/Curb

Off-Roadway

Four-way Inter

State Highway

Left turn same roadway

Fell from vehicle

Guardrail/Median Barrier

Median

T - Intersection

Left turn cross traffic

Other

Tree

Pedestrian

Sign Post

Angle

Parked Vehicle

Signal standard

Hit and run

Train

Shoulder Parking Lot Gore

Driveway Five-point or more Off Ramp

Building/Other Structure

Deer

Maint. Equip. - Not Moving

Dawn Dusk

Wet Water

Clear

Blown Debris

Rain

Fog/Smog/Smoke

Sand/Mud/Dirt/Oil/Gravel Ice Slush Snow

Cloudy

High winds

Sleet/Hail

Snow

Interstate

Y - Intersection

G28. Workzone Relationship

Dark-Unlit

G26. Road Condition

Dark-Lit

G27. Weather Condition (2)

Dry

Parking Lot/Private Drive

Traffic Circle/Round

Other non-fixed object

Daylight

County Road

RR Xing

Maint. Equip. - Moving

Animal (other than deer)

U.S. Highway

State Park

Path/Trail

Non-fixed Object

Bicyclist

W

Off Road

On Ramp

G29. Workzone Type (2)

Other fixed object

Crash of MV in road with:

Sideswipe

G23. Intersection Type

Utility pole/light support

Crossover

Roadside

G24. Roadway System

Roadway

G22. Crash Location

Bridge/Culvert

Head on

E

S

.

Overturn

Right turn cross traffic

N

G20. Longitude

Rear end slow or stop

Not Workzone Related Within Construction Zone Advance Warning Area

None Intermittent or Moving Work Lane Closure Lane Shift/Crossover Shoulder/Median Work Utility

WITNESS(ES) G30. First Name

MI

Last Name

G31. Address

G38. First Name

G34. State

M

F

MI

G35. Zip Code

G40. Phone Number

G41. City

G37. Age

G44. Sex

G42. State

M

F G48. Officer Signature

G47. Investigating Officer Name (Please Print)

G50. Reviewing Officer Initials

G51. Photos Taken

Y 4479140593

N

G43. Zip Code

G45. Age

G46. Badge Number

G49. Reviewing Badge Number

Last Name

G39. Address

G32. Phone Number

G33. City

G36. Sex

U

G17. Int. Hwy/County Road #

N

G21. First Harmful Event

G7. Killed

G11. Hwy/County Road #

G18. City Name

G25. Light Condition

G6. Vehicles

10-24 Time (2400)

G10. Street Name

G14. Distance

Y

Arrival Time (2400)

P

/

G9. Address Number

G13. Int.

of

G1. County

G52. Photographer and Badge #

MUCR Diagram/Narrative

Agency Number

Agency Case Number

Page

0 2

of

N1. Collision Diagram

North Arrow

N2. Collision Narrative

1772140596

V0. Vehicle #:

MUCR Vehicle

Agency Number

Agency Case Number

Page V4. License Plate Number

V12. Owner Name

Same as Driver

V5. Make

V6. Model Year

V13. Address

V7. Vehicle Model

V8. Vehicle Color

V14. City

V19. No Proof V17. Insurance Company Name of Insurance

None Non-Collision 1 2 3

Collision w/ Fixed Object 1 2 3 4

4

Animal

Cargo Loss/Shift

Attenuator/Cushion

Bicyclist Maintenance Equip.

Crossover Equipment Failure

Bridge Structure Culvert

Moving Vehicle

Fell/Jump from Vehicle

Curb

Parked Vehicle

Fire/Explosion

Ditch

Pedestrian Train

Immersion Jackknife

Embankment Fence

Slowing Vehicle

Median/Centerline

Guardrail

Stopped Vehicle in Road

Thrown/Falling Object

Mailbox

Off roadway/Left Off roadway/Right

Median Barrier Post/Pole/Support

Overturn/Rollover

Tree

Unit Separation Over Correcting/Steering

Other Fixed Object

School Bus

Train

Light Truck

Single-Unit Truck(2)

Truck/Trailer

Stationwagon/Van

Single-Unit Truck(3+)

Emergency Veh.

SUV

Farm Tractor

Commercial Bus

Motorcycle

Tractor/SemiTrailer

ATV

Other

Tractor(2)

Farm Equip.

RV

Tractor(3)

Unknown Truck

Channel-Painted

Officer

Channel-Physical

RR Flashing Signal

Flag Person

RR Signal and Gate Signal

Flashing Signal Yellow

Stop Sign

No Passing

Railroad Sign

None

Yield Sign

Y

V27. Device Functioning?

V33. Towed?

Yes

No

N

V34. Authority:

Overturn None Other

Bridge

Intersect two roads

Private Drive

Straight/Grade

Curve/Hillcrest

Curve/Level

Crossover

Straight/Hillcrest

Begin/End Divided Road

Curve/Grade

One-Way

Owner

Going Straight

Avoidance

Making Left Turn

Lane Change

Stopped

Leaving Parking

Slow/Stop in Road

Overtaking/Passing

Parked

Parking Position

Backing

Making U Turn

Making Right Turn

In Tow

None Right only Left Only Both Sides Separate Signed

Straight/Level

Police

Other

V29. Road Design

Flashing Signal Red

Under

V23. Initial Contact

Passenger Car

V28. Road Character

V26. Traffic Control Device

V22. Vehicle Configuration

V20. Sequence of Events

Collision w/ Person, Vehicle/Non-fixed Object 1 2 3 4

V18. Policy Number

Asphalt

2 Lane

3 Lane

4+

Frontage/Ramp

Parking Lot

One Way

1 Lane

Unpaved

V30. Divided?

Yes

No

V31. Center Turn Lane?

Yes

No

V32. Road Surface Type

Light

V25. Bikeway Type

V10. Speed Zone V11. Est. Speed

Heavy

V16. Zip Code

V15. State

V21. Vehicle Action

V3. Year

V9. Damage:

of

Owner Information

V24. Direction of Travel

V2. State

V1. Total Occupants

Concrete Dirt Gravel Other - See Narrative

V35. Towed By:

C1. Carrier ID Number: C2. Authority

US DOT

State

MC

Canada

C3. Carrier Name

C4. Carrier Address

Mexico

C9. Cargo Body Type

Commercial Vehicle Auto transporter

Flatbed

Bus