101
STATE OF NEVADA
DR#:
102
Hit & Run No
TRAFFIC ACCIDENT REPORT
Agency Name: Henderson Police Dept.
OCCURRED ON: (Highway number or Street Name)
Area:
City or County:
Henderson
STREET CODE::
N/A
201
1 At intersection with
STREET CODE:
N/A
202
2 or feet of
No.
V1
Pedes- Parked Pedal
Driver: train: Vehicle Cyclist: Other:
1 2 3 4 5
Explain “Other”
N/A
No.
V2
Pedes- Parked Pedal
Driver: train: Vehicle Cyclist: Other:
1 2 3 4 5
Explain “Other”
N/A
Issued by: Policy #: Date: From To
301
Issued by: Policy #: Date: From To
301
Address, City, State, Zip Code:
Address, City, State, Zip Code:
Name: (Last, First, Middle)
302
DOB
303
Name: (Last, First, Middle)
302
DOB
303
Street Address, City, State, Zip Code:
304
Street Address, City, State, Zip Code:
304
State/Driver’s License No.
305
Social Security No.
306
Sex
307
State/Driver’s License No.
305
Social Security. No.
306
Sex
307
State:
401
License No.:
402
Year/Make
403
Traveling
407
State
401
License No.:
402
Year/Make
403
Traveling
407
Color:
404
V.I.N.
405
Type:
406
Color
404
V.I.N.
405
Type
406
On
On
Owner’s Name: (Last, First, Middle)
408
Owner’s Name: (Last, First, Middle)
408
S/A
S/A
Owner’s Address: (Street, City, State, Zip Code)
409
Owner’s Address: (Street, City, State, Zip Code)
409
S/A
S/A
Training Unit(s): (Description)
N/A
410
Training Unit(s): (Description)
N/A
410
DATE/TIME OF
ACCIDENT
601
Sheet 1 of
Total No.
602
SEVERITY
1 Fatal 2 Injury Property Damage
603
Unusual Road
606
Collision
Type
607
Vehicles
CONDITION OF
SURFACE
604
WEATHER:
605
1 Holes/deep nuts
2 Loose mat on road
1 Head on
Date:
2 Rear end
Occupants
1 Dry 3 Snowy-icy
1 Clear 3 Raining
3 Obstruction in road
3 Sideswipe-mt
Day of Week
4 Const./repair zone
4 Sideswipe-ot
Pedestrians
2 Wet 4 Unknown
2 Cloudy4 Snowing
5 Reduced road width
5 Angle
Time (24 hr.)
6 Flooded
6 Backed into
Injured
5 Other
5 Other
7 Other (explain)
7 All others
8 No unusual conditio
8 Non-collision
Killed
Property-Damage Other Than Vehicles: (Describe)
N/A
608
Damage Amount
609
1
2
Owner Name and Address:
N/A
Notified of Damage:
1
Minor
1 Yes 2 No
2
Moderate
DRIVERS ONLY:
3
Major
1 2
1 2
1 2
1 2
4
Total
01 Going Straight
06 Stopped
11 Leaving alley or driveway
16 Traveling wrong way
5
No damage
02 Turning right
07 Parked
12 Passing other vehicle
17 Driverless-moving vehicle
701
03 Turning left
08 Entering park position
13 Changing lanes
18 Racing
04 Making U-turn
09 Leaving park position
14 Other turning movement
19 Other
05 Backing
10 Enter alley or dr. way
15 Crossed into opp. Lane
20 Unknown
CONTRIBUTING FACTORS:
EXPLAIN “OTHER” N/A
01 Excessive speed
07 Followed too closely
13 Mechanical defect (explain)
02 Speed too fast for conditions
08 Made improper turn
14 Road defect (explain)
03 Failed to yield right-of-way
09 Driver inattention
15 Other – not driver error
04 Drove left of center
10 Had been drinking
05 Disregard control device (explain)
11 Other improper driving
06 Improper overtaking
12 Pedestrian error (explain)
Describe What Happened:
Violation Charged:
Name:
Charge(s)
Citation/Booking No.:
704
Violation Charged:
Name:
Charge(s)
Citation/Booking No.:
Investigated by:
I. Henn
705
I.D. No.:
1202
706
Date:
707
Reviewed by:
708
Invest. is complete:
1 Yes 2 No
709
NHP 5 (Rev. 11-90)
Page of
101
STATE OF NEVADA
TRAFFIC ACCIDENT REPORT
DR#:
Henderson Police Department
102
DRIVERS OR PEDESTRIANS:
1 2 1 2
801
TESTS ADMINISTERED TO DRIVERS/PEDESTRIANS:
802
01
Apparently normal
06
H.B.D. – Not under influence
No.
Type
Administered at
Results
02
Apparently asleep
07
H.B.D. – Impairment unknown
N/A
N/A
N/A
N/A
03
Fatigued
08
Drugs - Under influence
04
Physical Impairment
09
Drugs – Impairment unknown
N/A
N/A
N/A
N/A
05
H.B.D. – Under influence
10
Condition Unknown
VISION OBSCURED BY:
1 2 1 2 1 2 1 2
803
01
Structure (explain)
05
Lack of/improper mirror
09
Sunglare
13
Other (explain)
02
Embankment
06
Rain, snow, ice, on windshield
10
Headlights
14
Vision not obscured
03
Hillcrest/curve
07
Other windshield obscurement
11
Vehicle design (explain)
15
Unknown if obscured
04
Bushes/trees
08
Vehicle load/occupants
12
Other parked/moving vehicle
No.:
Seat Belts:
804
Ejected:
805
Injury:
806
No.:
Seat Belts:
804
Ejected:
805
Injury:
806
1
Installed
Yes
Used
Yes
Yes
No
Class
Site
2
Installed
Used
Yes
No
Class
Site
No:
Position:
Name: (Last, First, Intial)
807
Address (Street, City, State)
808
809
810
Seat Belts:
811
Ejected:
812
Injury:
813
Age:
Sex:
Installed
Used
Yes
No
Class
Site
Y
Y
ROAD SURFACE:
815
ROAD WIDTH:
815
TRAFFIC CONTROL
816
SPEED: (Vehicles Only)
817
1
2
1
2
1
2
1
Asphalt
Traveled portion...
1
F
t.
01
Centerline
06
Stop sign
No. 1
No. 2
2
Concrete
Paved shouler…..
2
F
t.
02
Marked lanes
07
Yield sign
Post speed limit
1
3
Oiled
Total…………...
3
F
t.
03
Speed zone
08
No passing
zone
4
Dirt?Gravel
04
Signal light
09
Warning sign
Speed (est.)
2
5
Other
Storage/turn lane.
4
F
t.
05
Flashing signal
10
Other (explain)
Median width……
5
F
t.
11
Functioning
13
Not Functioning
Distance after
impact
3
12
Obscured
14
No control
VEHICLE DAMAGED AREAS:
1 2 1 2
818
VEHICLE REMOVED:
819
INJURED/FATALITIES TRANSPORTED:
820
01
Front
06
Rear
No.1
To:
N/A
02
Right front
07
Right Rear
By:
By;
N/A
03
Left front
08
Left rear
No. 2
To:
N/A
04
Right side
09
Top or underside
By:
By;
N/A
05
Left side
10
No damage
POLICE NOTIFIED:
821
MOTORCYCLE ONLY
HELMET USED:
822
WITNESSES: (Other Than Vehicle Occupant)
823
Date
Yes
No
Name N/A
Time
Number
Address N/A
Arrived Scene
Passenger
Name N/A
Elapsed
Time
Passenger
Address N/A
ADDITIONAL INFORMATION/DETAILS:N/A
824
NHP 5 (REV. 11-90)
D-2
