Instructions: If you checked a box under the qualifying vehicle column and a box under the criteria column, complete
the Motor Carrier Collision Report and submit to the address shown above. If you have any questions regarding filling
out the Motor Carrier Collision Report, please call 503-986-3507.
Motor Carrier Information
Driver Information
Complete the following two questions as if doing a recap of "Hours in Time Documents" at time of the collision..
At the Time of the Collision, Total Hours Driving Since Last Off-Duty Period
Total Hours on Duty During the Previous (Fill out only one, based on Time Documents)
Type of Waiver (sight, diabetes, amputee, etc.)
Driver Injury Information
Total Number of Passengers
Other Driver Injury Information
Total Number of Other Drivers
Total Number of Other Passengers
Total Number of Pedestrians
Total Number of Bicyclists
Other Motor Carrier Information (If 2 or more Motor Carriers were involved)
Motor Carrier Vehicle Information
Vehicle Type (Select appropriate type)
Cargo Body Type (Choose One)
Commodity Information
Collision Information
Conditions at Time of Collision
Describe what happened by checking all boxes that apply. Your Vehicle is always Number 1. If other vehicles were involved, complete
columns 2 and 3 to correspond to the actions of the same numbered vehicles listed above under "Other Driver Information".
Action
Action
Action
Action
Slowing - Stopping
Passing
Jackknife
Stopped
Changing Lanes
Overturn
Rear-End
Sideswipe
Separation of Units
Backing
Head-On
Fire
Making Right Turn
Skidding
Explosion
Making Left Turn
Vehicle Out Of Control
Cargo Shift
Making U Turn
Roll-Away
Cargo Spill (Hazardous)
Proceeding Straight
Controlled RR Crossing
Cargo Spill (Non-Hazardous)
Intersection
Uncontrolled RR Crossing
Entering Traffic
Ran Off Road
Other (Deer, Guardrail, etc)
Description of Collision by Carrier Official
Signature
I certify the information provided is true and accurate.
