ANNEXURE-I
GOVERNMENT OF TAMIL NADU – TRANSPORT DEPARTMENT
ACCIDENT STUDY REPORT
| ACCIDENT/ID | ||||||||||
| POLICE FIR NO | SECTION OF LAW | |||||||||
| POLICE STATION | ||||||||||
| Write number in box | DISTRICT | DD | Month | Year | ||||||
| NUMBER OF VEHICLES INVOLVED | ACCIDENT SEVERITY | ACCIDENT DATE | ||||||||
| NO OF DRIVER CASUALTIES | 1.Fatal | ACCIDENT DAY | 1.Sunday | 2.Monday | 3.Tuesday | |||||
| NO OF PASSENGER CASUALTIES | 2.Grievous injury | 4.Wednesday | 5.Thursday | 6.Friday | ||||||
| NO OF PEDESTRAIN CASUALTIES | 3.Minor injury (Hospitalized) | 7.Saturday | ||||||||
| 4.Minor injury(Not Hospitalized) | ||||||||||
| 5.Vehicle damage only(Non-injury) | Time(24 Hour Clock) | : | hrs | |||||||
| COLLISSION TYPE | JUNCTION TYPE | JUNCTION CONTROL | ROAD CATEGORY | ROAD CONDITION | ||||||
| 1.Head On | 1. | 1.Not at junction | 1.Expressway | 1.Good | ||||||
| 2.Hit from rear | 2 | 2.Police officer | 2.National Highway | 2.Poor | ||||||
| 3.Hit from side | 3. | 3.Traffic signals | 3.State Highway | 3.Muddy | ||||||
| 4.Side swipe | 4. | 4.Flashing signal | 4.MDR | 4.Roud work in progress | ||||||
| 5.Ran off road (no collision) | 5.Junction with more than 4 arms | 5.STOP sign | 5.ODR | 5.Sllppery surface | ||||||
| 6.Hit object in road | 6. | 6.GIVE WAY sign | 6.VDR | 6.Olly | ||||||
| 7.Hit object off road | 7.Rail crossing manned | 7.Uncontrolled | 7.Speed Breaker | |||||||
| 8.Hit parked vehicles | 8.Rail crossing unmanned | 8.Rulled / Pet holed | ||||||||
| 9.Hit pedestrian | 9.Bridge / Fly over | 9.Others | ||||||||
| 10.Hit animal | 10.None of these | |||||||||
| 11.Hit tree | ROAD NARROWING | |||||||||
| 12.Skidding | 1.None | 3.Two-way bridge | ||||||||
| 13.Overtuming – Collision | 2.One – way Bridge | 4.Other | ||||||||
| 14.Overturuming – No Collision | ||||||||||
| 15.Others | ||||||||||
| DESCRIPTION OF ACCIDENT | ||||||||||
| ACCIDENT LOCATION AND SITE CONDITION SKETCH | LAND MARK | |||||||||
| Show site in relation to well known places such as schools temples, churches, bridges and road junctions. Mark distances to theses places. Always give street name. Show road location features like drainage, culvents, potholes, street light. Mark the accident with a cross or arrow. | 1. Near school / collage | 9.Residental area | ||||||||
| 2.Near / Inside a village | 10.Open area | |||||||||
| 3. Near factory / Industrial area | 11. Near bus stop | |||||||||
| 4. Near religious place | 12. Near petrol pump | |||||||||
| 5. Near recreation place / cinema | 13. At pedestrian crossing | |||||||||
| 6. In bazaar | 14. Affected by encroachments | |||||||||
| 7. Near office Complex | 15. Narrow bridge or culvert | |||||||||
| 8. Near hospital | ||||||||||
| LIGHT CONDITIONS | ||||||||||
| 1.Day light | ||||||||||
| 2.Darkness – no street lights | ||||||||||
| 3. Darkness – with street lights on | ||||||||||
| 4. Twilight | ||||||||||
| CLINATE | ||||||||||
| 1. Fine | 6. Smoke Dust | |||||||||
| 2. Mist / Fog | 7. Strong wind | |||||||||
| 3. Cloudy | 8. Very Hot | |||||||||
| 4. Light rain | 9. Very cold | |||||||||
| 5.Heavy rain | 10. Other |
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| CONTRIBUTORY FACTOR | HIT AND RUN | ||||||
| 1. Fault of driver / rider | 7. Poor light condition | 1. Yes2. No | |||||
| 2. Fault of Cyclist | 8. Defect in road condition | ||||||
| 3. Fault of driver of another vehicle | 9. Bad weather | ||||||
| 4. Fault of pedestrian | 10. Falling of boulders | ||||||
| 5. Fault of passenger | 11. Neglect of civic bodies | ||||||
| 6. Defects in mechanical condition of vehicle | 12. Other cause | ||||||
| a. Break b. Tyre c. Light d. Gear box e. Gear box f. Horn etc | 13. Cause not known | ||||||
| VEHICLE DETAILS | VEHICLE – 1 | VEHICLE – 2 | |||||
| 1. Registration Number | 4. Fitness Certificate | ||||||
| 2. Make | 5. Insurance Certificate | ||||||
| 3. Model | 6. Tax | ||||||
| VEHICLE TYPE | |||||||
| 1. Motor Cycle | 9. Mini Bus | 17. Other vehicle | |||||
| 2. Scooter | 10. KSRTC Bus | 18. SAUV / MUV | |||||
| 3. Moped | 11. Truck | 19. Bicycle | |||||
| 4. Auto rickshaw | 12. Tempo | 20. Cycle rickshaw | |||||
| 5. Car | 13. Articulated Vehicle | 21. Hand drawn | |||||
| 6. Jeep | 14. Tractor | 22. Animal drawn | |||||
| 7. Taxi | 15. Light Goods van | 23. Other / Not known | |||||
| 8. Bus | 16. Heavy Goods van | 24. Other / known | |||||
| VEHICLE MANOEUVRE | 11. Driving | ||||||
| 1. Turning right | 12. Merging | ||||||
| 2. Turning left | 13. Crossing traffic stream | ||||||
| 3. Making U turn | 14. Stationery | ||||||
| 4. Temporarily held up | 15. Going a head overtaking | ||||||
| 5. Parked | 16. Going a head not overtaking | ||||||
| 6. Sudden stop | 17. Using private entrance | ||||||
| 7. Sudden start | 18. Reversing | ||||||
| 8. Overtaking from left | 19. Parking the vehicle | ||||||
| 9. Starting from near side | 20. Other / Known | ||||||
| 10. Starting from off – side | 21. Other / Not known | ||||||
| Vehicle Damage (Write number – refer graphic on last page) | DRIVER – 1 | DRIVER – 2 | |||||
| DRIVER DETAILS | |||||||
| NAME | |||||||
| AGE | |||||||
| SEX | 1. Male 2. Female | ||||||
| Driver Injury | 1. Fatal 2. Grievous 3. Minor Injury (Hospitalized) 4. Minor Injury ( Non hospitalized) 5. Not Injury | ||||||
| TYPE OF DRIVER INJURY (Write number – refer graphic on last page) | |||||||
| DRIVER ERROR | |||||||
| 1. None | 13. Improper turn | 24. a. DL. Validity | |||||
| 2. Consumption of alcohol or drugged | 14. Disregarded Police officer | b. No of accidents involved by the driver | |||||
| 3. Exceed lawful speed | 15. Disregarded traffic light sign | 25. a. Statement of eye witness on the accident spot | |||||
| 4. Did not give right way to pedestrian | 16. Disregarded STOP sign | b. De position of the other survived persons traveled in the vehicle | |||||
| 5. Followed too closely | 17. Starting off carelessly | 26. Analysis of cause of Accident and findings of the team | |||||
| 6. Over took on hill | 18. Wrong parking location | ||||||
| 7. Over took on curve | 19. Asleep or fatigued or sick | ||||||
| 8. Cut in sharply after over taking | 20. Lack of attention | ||||||
| 9. Other improper overtaking | 21. Bad use if head lights | 27. Remedial measure to prevent this accident | |||||
| 10. On wrong side of the road | 22. Failed to give way to vehicle | ||||||
| 11. Failed to signal | 23. Other | ||||||
| 12. Wrong signal |
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| INJURED PASSENGERS (complete tables using codes from bottom pane (Estimate age if not known) | |||||||||||
| NAME | AGE | SEX (M/F) | INJURY TYPE | IN VEHICLE NO (I.E.V1 OR V2) | |||||||
| 1. | |||||||||||
| 2. | |||||||||||
| 3. | |||||||||||
| INJURED PADESTRIANS ( complete tables using codes from bottom pane (Estimate age if not known) | |||||||||||
| NAME | AGE | SEX (M/F) | INJURY TYPE | IN VEHICLE NO (I.E.V1 OR V2) | |||||||
| 1. | |||||||||||
| 2. | |||||||||||
| 3. | |||||||||||
| ACCIDENT | PASSENGER POSSITION | PASSENGER ACTION | SEAT BELT / HELMET USED | PEDESTRAIN LOCATION | PEDESTRAIN CONTROL | ||||||
| 1. Fatal | 1.Front seat | 1. Sitting | 1. Yes | 1. On pedestrain Crossing | 1. Standing | ||||||
| 2. Grievous | 2. Rear seat | 2. Sanding | 2. No | 2. Who on 50 m of pedestrain crossing | 2. Crossing road | ||||||
| 3. Minor (H) | 3. Pillion rider | 3. Boarding | Alcohol | 3. On traffic island | 3. Waling along middle | ||||||
| 4. Minor (NH) | 4. Bus passenger | 4. Alighting | 1. Not suspected | 4. In centre of road (not (1 3) | 4. Waling along edge | ||||||
| 5. Non – Injury | 5. Back truck or pickup | 5. Falling | 2. Suspected | 5. On footpath | 5. Paying on road | ||||||
| 6. Other | 6. Other | 6. On shoulder | 6. Other | ||||||||
| 7. Other |
| MEMBER OF THE COMMITTEE | ||
| 1. Inspector of Police | Name | Signature |
| 2. Motor vehicle | Name | Signature |
| 3. Assistant / Junior Engineer, High ways | Name | Signature |