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..
Total Hours on Duty During the Previous
(Fill out only one, based on Time Documents)
(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
Signature
I certify the information provided is true and accurate.
