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MOTOR CARRIER CRASH REPORT

INSTRUCTIONS: IF YOU CHECKED A BOX UNDER THE QUALIFYING VEHICLE COLUMN AND A BOX UNDER THE CRITERIA COLUMN, COMPLETE THE MOTOR CARRIER CRASH REPORT AND SUBMIT TO THE ADDRESS SHOWN ABOVE. IF YOU HAVE ANY QUESTIONS REGARDING FILLING OUT THE MOTOR CARRIER CRASH REPORT, PLEASE CALL (503) 986-3507. * Required

QUALIFYING VEHICLE (Select one) * CRITERIA (Select all that apply)
MOTOR CARRIER INFORMATION
MOTOR CARRIER NAME *
US DOT NUMBER
AUTHORITY/FILE NUMBER
ADDRESS *
CITY *
STATE *
ZIP CODE *
DRIVER INFORMATION
FIRST NAME *
MIDDLE NAME
LAST NAME *
DATE OF BIRTH *
LENGTH OF EMPLOYMENT (YEARS)
Years Months
CDL / DL NUMBER *
STATE *
LICENSE CLASS
EXPIRATION DATE OF MEDICAL CERTIFICATE

COMPLETE THE FOLLOWING TWO QUESTIONS AS IF DOING A RECAP OF HOURS IN TIME DOCUMENTS AT TIME OF THE CRASH.

AT THE TIME OF THE CRASH, TOTAL HOURS DRIVING SINCE LAST OFF-DUTY PERIOD
TOTAL HOURS ON DUTY DURING THE PREVIOUS (FILL OUT ONE ONLY, BASED ON TIME DOCUMENTS)
 7 CONSECUTIVE DAYS
8 CONSECUTIVE DAYS
DOES YOUR DRIVER HAVE A MEDICAL WAIVER
TYPE OF WAIVER (SIGHT, DIABETES, AMPUTEE, ETC.)
DRIVER INJURY INFORMATION
YOUR DRIVER KILLED
YOUR DRIVER INJURED
RELIEF DRIVER KILLED
RELIEF DRIVER INJURED
TOTAL NUMBER OF PASSENGERS
Killed Injured
OTHER DRIVER INJURY INFORMATION
TOTAL NUMBER OF OTHER DRIVERS
Killed
Injured
TOTAL NUMBER OF OTHER PASSENGERS
Killed
Injured
TOTAL NUMBER OF PEDESTRIANS
Killed
Injured
TOTAL NUMBER OF BICYCLISTS
Killed
Injured
OTHER MOTOR CARRIER INFORMATION (If 2 or more Motor Carriers were involved)
MOTOR CARRIER NAME
VEHICLE PLATE & STATE
DRIVER'S FIRST AND LAST NAME
DRIVER'S LICENSE NO. & STATE
MOTOR CARRIER NAME
VEHICLE PLATE & STATE
DRIVER'S FIRST AND LAST NAME
DRIVER'S LICENSE NO. & STATE
MOTOR CARRIER NAME
VEHICLE PLATE & STATE
DRIVER'S FIRST AND LAST NAME
DRIVER'S LICENSE NO. & STATE
MOTOR CARRIER VEHICLE INFORMATION
YEAR *
MAKE *
UNIT NUMBER
TRUCK/TRACTOR/BUS
LICENSE PLATE NO. & STATE *
TOTAL NO. OF AXLES
(including trailers)
VEHICLE TYPE (Select appropriate type)
CARGO BODY TYPE (Choose One)
TOTAL LENGTH OF VEHICLE/COMB
Feet Inches
TOTAL WIDTH OF VEHICLE/COMB
Feet Inches
CARGO WEIGHT
GROSS VEHICLE WEIGHT
COMMODITY INFORMATION
COMMODITY BEING TRANSPORTED AT TIME OF CRASH
WAS A HAZARDOUS COMMODITY BEING HAULED
WAS HAZARDOUS MATERIAL RELEASED FROM THE VEHICLE CARGO
(not a fuel release)
HAZARD CLASS
CRASH INFORMATION
LOCATION OF CRASH (nearest city or town) *
HIGHWAY AND MILEPOINT/STREET/COUNTY ROAD *
DIRECTION OF YOUR VEHICLE *
DATE OF CRASH *
TIME OF CRASH *
CONDITIONS AT TIME OF CRASH
WEATHER Other
ROAD SURFACE Other
LIGHT CONDITION Other

DESCRIBE WHAT HAPPENED BY CHECKING ALL BOXES THAT APPLY. YOUR VEHICLE IS ALWAYS NO.1. IF OTHER VEHICLES WERE INVOLVED, COMPLETE COLUMNS 2 & 3 TO CORRESPOND TO THE ACTIONS OF THE SAME NUMBERED VEHICLES LISTED ABOVE UNDER "OTHER DRIVER INFORMATION".

VEHICLES ACTION VEHICLES ACTION VEHICLES ACTION
1 2 3 1 2 3 1 2 3
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 Other (Deer, Guardrail, etc)
Entering Traffic Ran Off Road
DID YOUR VEHICLE STRIKE A PARKED VEHICLE
WAS YOUR PARKED VEHICLE STRUCK BY ANOTHER VEHICLE
DESCRIPTION OF CRASH BY CARRIER OFFICIAL
SIGNATURE
NAME OF PERSON SIGNING REPORT *
TITLE *
TELEPHONE NUMBER *
ext.
SIGNATURE *
 I CERTIFY THE INFORMATION PROVIDED IS TRUE AND ACCURATE
DATE *
11/20/2024
Read the letters:
More Info 		And type them into this field:
Letters are NOT case sensitive and numbers one(1) and zero(0) are not used.

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