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| Question | Answer |
|---|---|
| Form Name | Dr Form 40 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | nebraska dr 40 fillable form |
*DR40* |
State of Nebraska |
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Investigator’s Motor Vehicle Accident Report |
Sheet of |
Total Number |
Local No./ |
Agency |
of Vehicles |
District |
Case |
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No. |
A/1 |
DATE |
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M / D |
D / Y |
Y |
Y |
Y |
S M T W TH F S |
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OF |
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ACCIDENT |
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A/2 |
PLACE |
COUNTY |
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OF |
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ACCIDENT |
CITY |
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STREET/ |
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ROAD ON WHICH |
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HIGHWAY NO. |
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ACCIDENT OCCURRED |
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HIT & RUN? |
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YES |
NO |
(In Military Time) |
STATE USE ONLY |
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TIME OF |
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ACCIDENT |
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POLICE |
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LATITUDE |
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NOTIFIED |
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PRIVATE |
YES |
NO |
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PROPERTY? |
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LONGITUDE |
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YES |
NO |
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STREET? |
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C |
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FEET |
N S E W OF |
HIGHWAY NO. |
SHOULD LOCATION HAVE |
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DISTANCE FROM |
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MILEPOST |
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ENGINEERING STUDY? |
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MILEPOST |
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D |
IF AT INTERSECTION |
IF NOT AT INTERSECTION |
YES |
NO |
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NAME OF INTERSECTING ROADWAY |
FEET MILES N S E W OF NEAREST STREET, BRIDGE, RAILROAD CROSSING |
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V1/M |
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IF ACCIDENT WAS OUTSIDE CITY LIMITS, INDICATE DISTANCE FROM NEAREST TOWN
V2/M |
MILES |
N |
S |
E W |
AND MILES |
N S |
E |
W |
OF NEAREST |
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CITY OR TOWN |
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R. WORK |
R1 |
R2 |
R3 |
R4 S. PEDESTRIAN |
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S1 |
S2 |
S3 S4 |
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ZONE |
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CLASSIFICATION |
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(Fill in all that apply) |
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CODES |
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CODES |
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TRUCK & BUS |
NONE CONTINUATION
VEHICLE NO. 1
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DRIVER’S |
NO. |
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LICENSE |
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V1/N |
DRIVER |
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DRIVER |
CITY, |
V2/N |
ADDRESS |
STATE, ZIP |
OWNER |
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OWNER |
CITY, |
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ADDRESS |
STATE, ZIP |
H |
LICENSE |
NO. |
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PLATE |
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VEHICLE |
YEAR |
MAKE |
MODEL |
BODY |
V1/O |
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STYLE |
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VEHICLE ID |
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NO. (VIN) |
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V2/O |
TOWED TO |
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TOWED BY |
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VEHICLE NO. 2 |
DRIVER’S |
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NO. |
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LICENSE |
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V1/P |
DRIVER |
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V2/P |
DRIVER |
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CITY, |
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ADDRESS |
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STATE, ZIP |
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OWNER |
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OWNER |
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CITY, |
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ADDRESS |
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STATE, ZIP |
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V1/Q |
LICENSE |
NO. |
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PLATE |
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V2/Q |
VEHICLE |
YEAR |
MAKE |
MODEL |
BODY |
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STYLE |
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VEHICLE ID |
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K |
NO. (VIN) |
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TOWED TO |
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TOWED BY |
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Complete this section for all injured persons
(Complete a continuation report, if more than three were injured)
VEH. # |
NAME |
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ADDRESS |
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LOCAL NO. |
MEDICAL |
EMS |
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FACILITY |
SERVICE |
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NAME |
NAME |
VEH. # |
NAME |
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ADDRESS |
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LOCAL NO. |
MEDICAL |
EMS |
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FACILITY |
SERVICE |
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NAME |
NAME |
VEH. # |
NAME |
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ADDRESS |
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LOCAL NO. |
MEDICAL |
EMS |
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FACILITY |
SERVICE |
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NAME |
NAME |
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STATE |
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SEX |
FEMALE |
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(Of License) |
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MALE |
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PHONE |
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LOCAL NO. |
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DATE OF BIRTH |
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MM / DD / YYYY |
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PHONE |
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LOCAL NO. |
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V1/2 |
CITATION |
YES |
CITATION |
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PENDING |
NO |
NO. |
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V1/3 |
YEAR |
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STATE |
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(Plate Expires) |
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(Of Plate) |
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COLOR |
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ESTIMATED |
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V1/4 |
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DAMAGE |
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INSURANCE |
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COMPANY |
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V1/5 |
POLICY NO. |
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V1/6 |
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STATE |
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SEX |
FEMALE |
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(Of License) |
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MALE |
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PHONE |
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LOCAL NO. |
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V2/1 |
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DATE OF BIRTH |
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V2/2 |
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MM / DD / YYYY |
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PHONE |
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LOCAL NO. |
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CITATION |
YES |
CITATION |
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V2/3 |
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PENDING |
NO |
NO. |
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YEAR |
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STATE |
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V2/4 |
(Plate Expires) |
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(Of Plate) |
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COLOR |
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ESTIMATED |
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V2/5 |
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DAMAGE |
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INSURANCE |
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COMPANY |
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V2/6 |
POLICY NO. |
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DATE OF BIRTH |
1 |
2 |
3 |
4 |
5 |
SEX |
Seat |
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Body |
Injury |
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(MM / DD / YYYY) |
Eject |
Trans. M F |
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Position |
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Region |
Sev. |
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EMS RUN
REORT
NO.
EMS RUN
REPORT
NO.
EMS RUN
REPORT
NO.
DR Form 40, Jan 02/
THE FOLLOWING INFORMATION IS REQUIRED FOR ALL ACCIDENTS
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Investigation |
INDICATE BY DIAGRAM WHAT HAPPENED |
Agency Case No.: |
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made at scene? |
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Indicate North |
Yes |
No |
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by Arrow |
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DESCRIPTION OF ACCIDENT BASED ON OFFICER’S INVESTIGATION
PROPERTY
OBJECT DAMAGED
OBJECT DAMAGED
OWNER NAME |
ADDRESS |
PHONE |
APPROX. COST OF DAMAGE |
OWNER NAME |
ADDRESS |
PHONE |
APPROX. COST OF DAMAGE |
WITNESSES |
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NAME |
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ADDRESS |
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PHONE |
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NAME |
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ADDRESS |
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PHONE |
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VEHICLE MOVEMENT |
POINT OF IMPACT AND |
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AIRBAG DEPLOYED |
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RESTRAINT USE |
TOTAL |
VEH |
VEH |
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BEFORE COLLISION |
MOST DAMAGED AREA |
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OCCUPANTS |
1 |
2 |
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VEH. |
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ROAD OR |
(Enter numbers for each vehicle) |
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N S E W |
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NO. |
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HIGHWAY NAME |
VEHICLE 1 |
VEHICLE 2 |
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VEHICLE 1 |
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VEHICLE 1 |
ALCOHOL |
Driver |
Driver |
Pedes- |
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1 |
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POINT |
POINT |
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TESTING |
No. 1 |
No. 2 |
trian |
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OF |
OF |
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ALCOHOL |
Y |
Y |
Y |
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2 |
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IMPACT |
IMPACT |
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MOST |
MOST |
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LEVEL |
N |
N |
N |
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DAMAGED |
DAMAGED |
1 Deployed – front |
1 |
None used – vehicle occupant |
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AREA |
AREA |
TESTED |
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1 |
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07 |
Making |
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2 Deployed – side |
2 |
Lap & shoulder belt used |
BAC LEVEL |
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3 |
Shoulder belt only used |
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3 |
Deployed – both front/side |
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08 |
Entering |
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4 |
Not deployed |
4 |
Lap belt only used |
ALCOHOL/ |
Driver |
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Driver |
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2 |
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5 |
Child safety seat used |
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traffic lane |
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5 |
Not applicable/No airbag available |
6 |
Child booster seat used |
DRUGS |
No. 1 |
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No. 2 |
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09 |
Leaving |
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6 Unknown |
7 |
Helmet used |
SUSPECTED |
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01 |
Essentially straight |
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traffic lane |
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8 |
Restraint use unknown |
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02 |
ahead |
10 |
Parked |
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VEHICLE 2 |
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VEHICLE 2 |
1 |
Neither alcohol nor drugs suspected |
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Backing |
11 |
Slowing or |
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2 |
Yes – alcohol suspected |
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03 |
Changing lanes |
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stopped in |
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04 |
Overtaking/ |
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traffic |
00 None |
11 Total (all areas) |
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3 Yes – drugs suspected |
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Passing |
12 |
Other |
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4 |
Yes – alcohol & drugs suspected |
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05 |
Turning right |
09 Top & windows |
12 Other |
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13 |
Unknown |
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5 Unknown |
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06 |
Turning left |
10 Undercarriage |
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OFFICER NO. |
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TROOP/ |
DEPARTMENT |
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Photographs |
YES |
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TEAM/ |
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BEAT |
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taken? |
NO |
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INVESTIGATOR NAME (Print or Type) |
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INVESTIGATOR SIGNATURE |
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DATE OF |
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REPORT