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)
	COMMERCIAL TRUCK (GVWR OVER 10,000 LBS OR ACTUAL WT AT TIME OF CRASH EVEN IF GVWR IS SET UNDER 10,000 LBS )		ANY PERSON SUSTAINING A FATALITY (WITHIN 30 DAYS OF THE CRASH)
	HAZARDOUS MATERIAL PLACARD		ANY PERSON SUSTAINING INJURIES REQUIRING TREATMENT AWAY FROM THE SCENE
	COMMERCIAL BUS (DESIGNED FOR 8 OR MORE PASSENGERS)
	FARM TRUCK INTERSTATE (OVER 10,000 LBS.)		ANY VEHICLE INCURRING DISABLING DAMAGE REQUIRING REMOVAL FROM THE SCENE BY A TOW TRUCK OR ANOTHER MOTOR VEHICLE
	FARM TRUCK FOR-HIRE (4 OR MORE AXLES)
	FARM TRUCK TOWING TRIPLE TRAILERS
	FARM TRUCK (OVER 80,000 LBS.)

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

A B C D M

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 YES NO		TYPE OF WAIVER (SIGHT, DIABETES, AMPUTEE, ETC.)

DRIVER INJURY INFORMATION
YOUR DRIVER KILLED YES NO	YOUR DRIVER INJURED YES NO	RELIEF DRIVER KILLED YES NO	RELIEF DRIVER INJURED YES NO	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)

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 YES NO	WAS HAZARDOUS MATERIAL RELEASED FROM THE VEHICLE CARGO (not a fuel release) YES NO	HAZARD CLASS

CRASH INFORMATION
LOCATION OF CRASH (nearest city or town) *	HIGHWAY AND MILEPOINT/STREET/COUNTY ROAD *	DIRECTION OF YOUR VEHICLE * N S E W
DATE OF CRASH *	TIME OF CRASH *

CONDITIONS AT TIME OF CRASH
WEATHER	Clear	Rain	Snow	Cloudy	Sleet	Fog	Other
ROAD SURFACE	Dry	Wet	Snowy	Icy	Other
LIGHT CONDITION	Day	Dawn	Dusk	Artificial Lights		Dark	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".

SIGNATURE
NAME OF PERSON SIGNING REPORT *	TITLE *	TELEPHONE NUMBER * ext.

SIGNATURE *

I CERTIFY THE INFORMATION PROVIDED IS TRUE AND ACCURATE

DATE *

04/19/2024

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.

Oregon DOT - Commerce and Compliance Division	Contact Us Privacy Search

VEHICLE TYPE (Select appropriate type)
	Triples (tractor with 3 trailers)	Standard Tractor/Semi Trailer	Heavy Haul
	Triples (truck with 2 trailers)	Straight Truck	Bus/Van (8 or more passenger capacity)
	Straight truck-full trailer	Tractor only	Auto/Pickup
	Doubles (any)	Saddlemount

CARGO BODY TYPE (Choose One)
	Van	Flatbed	Tanker	Container	Pole
	Dump	Belly-Dump	Car Carrier	Livestock	Mobile Home Toter
	Passenger	Drop-Box	Garbage	Bulk-Hopper	Mixer
	Saddlemount	Wrecker	Fixed Load	Heavy Haul	Utility

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 YES NO							WAS YOUR PARKED VEHICLE STRUCK BY ANOTHER VEHICLE YES NO
DESCRIPTION OF CRASH BY CARRIER OFFICIAL

MOTOR CARRIER CRASH REPORT

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