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Pedestrian Struck By Motor Vehicle Medical Examination Example
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DESCRIPTION OF THE ACCIDENT WAS THIS A WITNESSED ACCIDENT (NAME AND CONTACT NUMBERS FOR WITNESS(ES)) - IF YES, WHAT DOES WITNESS SAY HAPPENED? IF UNWITNESSED, WHAT DO LAW ENFORCEMENT SUSPECT HAPPENED? IS IT KNOW WHERE THE VICTIM WAS WHEN STRUCK - THE SHOULDER OF THE ROAD, IN AN
INTERSECTION , MID BLOCK, OPEN ROADWAY, ETC. VEHICLE(S) - IF VEHICLE IS AVAILABLE, PHOTOGRAPH FROM ALL SIDES INCLUDING THE FRONT OF THE VEHICLE WITH A RULER SHOWING THE HEIGHT OF THE BUMPER FROM THE GROUND TO THE FIRST PROTRUSION.) DID THE VEHICLE STOP AT THE SCENE? YES NO IF NO, DESCRIBE WITNESSES POSSIBLE LEADS ABOUT THE KIND OF VEHICLE INVOLVED: IF YES, ARE CHARGES PENDING AGAINST THE DRIVER OF THE VEHICLE? YES NO IF YES, WHAT ARE THE CHARGES: TYPE OF VEHICLE: AUTO PICKUP TRUCK VAN BUS ATV MOTORCYCLE BICYCLE MAKE: MODEL: YEAR: BUMPER HEIGHT (ROAD TO PROJECTION ON BUMPER): HOOD HEIGHT (ROAD TO PROJECTION ON HOOD): DESCRIBE TRACE EVIDENCE FOUND ON THE VEHICLE AND FROM UNDERCARRIAGE, IF
APPLICABLE: WERE OTHER VEHICLE(S) INVOLVED: IF "YES" DESCRIBE PER ABOVE: THE VEHICLE WAS TRAVELING: NORTH SOUTH EAST WEST UNK WHAT LANE: INSIDE MIDDLE OUTSIDE OTHER: UNK IF SKID MARKS VISIBLE, WHAT IS LENGTH: FT POLICE HAVE ESTIMATED SPEED OF VEHICLE TO BE: MPH DRIVER OF VEHICLE WAS THERE ANY INDICATION THAT THE DRIVER OF THE VEHICLE WAS UNDER THE INFLUENCE
OF ALCOHOL OR DRUGS, EXPLAIN: DID THE OPERATOR OF THE VEHICLE GIVE ANY WARNING OF APPROACH: NAME OF INVESTIGATOR DMI# PEDESTRIAN STRUCK BY MOTOR VEHICLE NAME OF DECEDENT: This form is to completed in addition to the ROD form in these guidelines THE DECEDENT DESCRIBE THE VICTIM'S CLOTHING: LIGHT MEDIUM DARK THE BODY WAS FOUND FT. FROM THE POINT OF IMPACT. THE BODY WAS FOUND FT. OFF/ON THE ROADWAY. THE VICTIM WAS: WALKING RUNNING STANDING UNKNOWN IN A CROSSWALK – EXPLAIN: HEADING IN THE DIRECTION: NORTH SOUTH EAST WEST UNKNOWN THE FLOW OF TRAFFIC WAS: WITH AGAINST CROSSING THE FLOW APPARENT CONDITION OF TH E PEDESTRIAN (INCLUDING ALCOHOL, DRUGS, ETC. -- INDICATE
DISTANCE OF NEAREST LIQUOR ESTABLISHMENT IF KNOWN) ENVIRONMENTAL FACTORS ROAD CONDITION: DRY WET SNOW ICE MUD OTHER: AREA: BUSINESS INDUST SCHOOL PLAYGROUND RESIDENTIAL OTHER: ROAD FACTORS ROAD SURFACE: CONCRETE ASPHALT BRICK GRAVE DIRT OTHER: NUMBER OF TRAFFIC LANES: MEDIAN(S): SIDEWALKS: POSTED SPEED: MPH VEHICLES PARKED NEXT TO ROADWAY - DESCRIBE: ROADWAY IRREGULARITIES: CONSTRUCTION: YES NO EXPLAIN: HOW ACCESSIBLE IS THIS ROAD TO PEDESTRIANS? IF GATES ARE PRESENT, WERE THEY OPEN? IS THIS AREA KNOWN FOR FREQUENT PEDESTRIAN TRAFFIC? YES NO IS THE AREA KNOWN FOR OTHER PEDESTRIAN ACCIDENTS? YES NO
INTERSECTION , MID BLOCK, OPEN ROADWAY, ETC. VEHICLE(S) - IF VEHICLE IS AVAILABLE, PHOTOGRAPH FROM ALL SIDES INCLUDING THE FRONT OF THE VEHICLE WITH A RULER SHOWING THE HEIGHT OF THE BUMPER FROM THE GROUND TO THE FIRST PROTRUSION.) DID THE VEHICLE STOP AT THE SCENE? YES NO IF NO, DESCRIBE WITNESSES POSSIBLE LEADS ABOUT THE KIND OF VEHICLE INVOLVED: IF YES, ARE CHARGES PENDING AGAINST THE DRIVER OF THE VEHICLE? YES NO IF YES, WHAT ARE THE CHARGES: TYPE OF VEHICLE: AUTO PICKUP TRUCK VAN BUS ATV MOTORCYCLE BICYCLE MAKE: MODEL: YEAR: BUMPER HEIGHT (ROAD TO PROJECTION ON BUMPER): HOOD HEIGHT (ROAD TO PROJECTION ON HOOD): DESCRIBE TRACE EVIDENCE FOUND ON THE VEHICLE AND FROM UNDERCARRIAGE, IF
APPLICABLE: WERE OTHER VEHICLE(S) INVOLVED: IF "YES" DESCRIBE PER ABOVE: THE VEHICLE WAS TRAVELING: NORTH SOUTH EAST WEST UNK WHAT LANE: INSIDE MIDDLE OUTSIDE OTHER: UNK IF SKID MARKS VISIBLE, WHAT IS LENGTH: FT POLICE HAVE ESTIMATED SPEED OF VEHICLE TO BE: MPH DRIVER OF VEHICLE WAS THERE ANY INDICATION THAT THE DRIVER OF THE VEHICLE WAS UNDER THE INFLUENCE
OF ALCOHOL OR DRUGS, EXPLAIN: DID THE OPERATOR OF THE VEHICLE GIVE ANY WARNING OF APPROACH: NAME OF INVESTIGATOR DMI# PEDESTRIAN STRUCK BY MOTOR VEHICLE NAME OF DECEDENT: This form is to completed in addition to the ROD form in these guidelines THE DECEDENT DESCRIBE THE VICTIM'S CLOTHING: LIGHT MEDIUM DARK THE BODY WAS FOUND FT. FROM THE POINT OF IMPACT. THE BODY WAS FOUND FT. OFF/ON THE ROADWAY. THE VICTIM WAS: WALKING RUNNING STANDING UNKNOWN IN A CROSSWALK – EXPLAIN: HEADING IN THE DIRECTION: NORTH SOUTH EAST WEST UNKNOWN THE FLOW OF TRAFFIC WAS: WITH AGAINST CROSSING THE FLOW APPARENT CONDITION OF TH E PEDESTRIAN (INCLUDING ALCOHOL, DRUGS, ETC. -- INDICATE
DISTANCE OF NEAREST LIQUOR ESTABLISHMENT IF KNOWN) ENVIRONMENTAL FACTORS ROAD CONDITION: DRY WET SNOW ICE MUD OTHER: AREA: BUSINESS INDUST SCHOOL PLAYGROUND RESIDENTIAL OTHER: ROAD FACTORS ROAD SURFACE: CONCRETE ASPHALT BRICK GRAVE DIRT OTHER: NUMBER OF TRAFFIC LANES: MEDIAN(S): SIDEWALKS: POSTED SPEED: MPH VEHICLES PARKED NEXT TO ROADWAY - DESCRIBE: ROADWAY IRREGULARITIES: CONSTRUCTION: YES NO EXPLAIN: HOW ACCESSIBLE IS THIS ROAD TO PEDESTRIANS? IF GATES ARE PRESENT, WERE THEY OPEN? IS THIS AREA KNOWN FOR FREQUENT PEDESTRIAN TRAFFIC? YES NO IS THE AREA KNOWN FOR OTHER PEDESTRIAN ACCIDENTS? YES NO