Form 4100-174 PDF Details

Understanding the complexities and the mandatory nature of Form 4100-174 is essential for anyone involved in off-highway vehicle (OHV) incidents in Wisconsin. This form serves as a vital tool for reporting crashes involving snowmobiles, all-terrain vehicles (ATVs), utility-terrain vehicles (UTVs), or off-highway motorcycles (OHMs) that result in death or injuries requiring medical attention by a physician. The requirement stipulates that the operator must report such incidents to a conservation warden or a local law enforcement agency as soon as possible and submit a written report within 10 days to the Department of Natural Resources. Failure to comply with this requirement could result in a forfeiture of up to $250.00. The form collects detailed information about the incident, including operator and vehicle information, crash incident criteria, and a narrative of the event, all intended for investigatory purposes. Furthermore, it highlights the significance of adhering to Wisconsin’s Open Records Law by ensuring that personal information collected is used appropriately and may be disclosed to requesters as required by law. The inclusion of specific details such as the type of OHV involved, the nature of injuries, and a description of the crash scene provides a comprehensive view necessary for the appropriate handling of such incidents.

QuestionAnswer
Form Name Form 4100-174
Form Length 2 pages
Fillable? Yes
Fillable fields 90
Avg. time to fill out 10 min
Other names Form 4100-174, WI DNR form 4100-174, Wisc DNR 4100-174, DNR 4100-174

Form Preview Example

Send Report To: Off-Highway Vehicle Program – LE/8

Off-Highway Vehicle (OHV) Incident

Department of Natural Resources

Operator Report

 

PO Box 7921

 

Madison, WI 53707-7921

Form 4100-174 (R 11/18)

Page 1 of 2

Vehicle Type:

Notice: For the purpose of this report an off-highway vehicle (OHV) means snowmobile, all-terrain vehicle (ATV), utility-terrain vehicle (UTV) or off-highway motorcycle (OHM). The operator of any ATV, UTV or snowmobile involved in a crash incident on public or private lands that results in death or injuries requiring treatment by a physician is required by sections 350.15, 23.33(7) and any OHM involved in a crash incident on public lands that results in death or injuries requiring treatment by a physician is required by section 23.335(18)

Wis. Stats., to report the incident as soon as possible to a conservation warden or a local law enforcement agency, and to submit a written report within 10 days to the Department of Natural Resources. Failure to complete this form as required may result in a forfeiture of up to $250.00. Personal information collected will be used for investigatory purposes and may be provided to requesters to the extent required by Wisconsin’s Open Records Law (ss. 19.31-19.39, Wis. Stats.).

Crash Incident Criteria

Incident Date

Day of Week

Time of Day

am

City or Township

County

State

Location of Incident:

 

 

pm

 

 

 

WI

 

 

 

Number of Vehicles in Crash

 

 

 

Private Land

Hwy. Right-of-way

Waterway

 

 

 

Injuries Requiring Medical Treatment?

Y

N

 

 

 

 

 

Public Land

Public Trail

 

Route

 

Death Related to Incident?

 

Y

N

Public Road

Private Trail

 

 

 

Disappearance of Person Indicating Injury or Death?

Y

N

Operator Information

Operator Name (First, Middle, Last)

 

Phone Number

(ext.)

Yes No N/A

 

 

 

 

Eye Protection/Face Shield?

Address

 

Date of Birth

Age

Wearing Helmet?

 

 

 

 

Seat Belt Used?

City

State ZIP Code

Gender:

 

Injured?

 

 

Male

Female

Minor–No Permanent Injury

Description of Injury

 

 

 

Major–Required Hospitalization

Completed OHV-Specific DNR Safety Training Course?

Yes - State

 

 

 

 

 

 

No - Online course?

Yes

No

 

Unknown

 

 

Vehicle Information (Vehicle A)

Operator Experience:

0 - 100 Hours

Over 100 Hours

OHV Type:

Snowmobile

ATV

UTV

OHM

Other

 

 

 

 

OHV is:

Rented

Borrowed

Owned

 

 

 

 

 

 

Owner Name (First, Middle, Last)

Same as Operator

 

 

Phone Number

(ext.)

Address

 

 

 

 

City

 

 

 

State ZIP Code

Make

 

Model

 

 

Year

Decal Number

 

Exp. Date

State

Vehicle ID Number

Engine Size

Studs/Chains?

Estimated Speed

Designed to Seat How Many?

 

 

 

 

CC

Yes

No

 

MPH

 

 

Passengers

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Passenger Name (First, Middle, Last)

 

 

Phone Number

(ext.)

 

Yes No N/A

 

 

 

 

 

 

 

 

Eye Protection/Face Shield?

 

Address

 

 

 

 

Date of Birth

Age

Wearing Helmet?

 

 

 

 

 

 

 

 

 

Seat Belt Used?

 

City

 

 

State

ZIP Code

Gender:

 

Injured?

 

 

 

 

 

 

 

Male

Female

 

Minor–No Permanent Injury

Description of Injury

 

 

 

 

 

 

 

Major–Required Hospitalization

 

 

 

 

 

 

 

 

 

Fatal

 

OHV Incident – Operator Report

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form 4100-174 (R 11/18)

 

Page 2 of 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Party Involved

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (First, Middle, Last)

 

 

 

 

 

 

 

 

Phone Number

 

 

(ext.)

Describe Involvement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

 

 

Age

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Injured?

 

 

 

 

 

 

 

 

 

 

 

City

 

State

 

 

ZIP Code

 

 

Gender:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

 

Female

 

 

 

Minor–No Permanent Injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Major–Required Hospitalization

Description of Injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fatal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Vehicle Involved

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vehicle Type:

Snowmobile

ATV

 

 

UTV

OHM

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Decal Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Operator Name (First, Middle, Last)

 

 

 

 

 

 

 

Date of Birth

 

Age

 

 

Gender:

 

 

Phone Number

(ext.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Witnesses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First, MI, Last Name

 

 

 

 

 

 

Address

 

 

 

 

 

 

Birthdate

 

 

Phone Number

 

Sex

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

F

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

F

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

F

Type and Cause of Accident

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Environment

 

 

 

 

 

 

 

 

 

 

 

Type of Incident: (select all that apply)

 

 

Activity at Time of Incident:

 

 

 

Weather:

 

 

 

 

Visibility:

 

 

 

Fell/ejected from OHV

 

 

 

 

Recreational

 

 

 

 

 

 

 

 

 

Foggy - Mist

 

 

 

 

Day

 

 

 

Night

 

Collision with fixed object

 

 

 

 

Agricultural

 

 

 

 

 

 

 

 

 

Raining

 

 

 

 

 

 

Good

 

 

 

Collision with another OHV

 

 

 

 

Sanctioned Race (ATV/UTV only)

 

 

 

 

Snowing

 

 

 

 

 

 

Fair

 

 

 

Collision with moving motor vehicle

 

 

Construction

 

 

 

 

 

 

 

 

 

Clear

 

 

 

 

 

 

Poor

 

 

 

 

 

Hunting

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Collision with parked motor vehicle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

Temperature

 

 

 

 

Road Condition:

 

 

 

Broke through ice

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

°F

 

 

Dry

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What in Your Opinion Contributed to

 

 

 

 

 

 

 

 

 

 

 

Driven into open water

 

 

the Incident?

 

 

 

 

 

 

 

 

Trail Condition:

 

 

 

 

 

 

Wet

 

 

 

OHV rolled over/Tip over

 

 

 

 

Drinking or Drugs

 

 

 

 

 

 

Icy

 

 

 

 

 

 

Snow Covered

 

 

 

 

 

 

Vehicle speed

 

 

 

 

 

 

 

 

 

Smooth

 

 

 

 

 

 

 

 

Struck fence or cable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Equipment failure

 

 

 

 

 

 

 

 

 

 

 

 

Icy

 

 

 

 

 

 

 

 

 

 

 

 

 

Rough

 

 

 

 

 

 

 

 

 

Injured by contact with part of OHV

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Failure to yield

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gravel

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Muddy

 

 

 

 

 

 

 

 

 

Pedestrian struck by OHV

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Inexperience

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dry

 

 

 

 

 

 

Paved

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Being pulled by OHV

 

 

 

 

Trail conditions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

Other

 

 

 

Other

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Describe What Happened (Sequence of events leading up to the incident)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please double check your report for accuracy. Pursuant to s. 350.15(4), Wis. Stats., and NR64.10, Wis. Admin. Code, this report may

not be used as evidence in any trial.

 

 

Printed Name of Operator

Signature of Operator

Date Signed (MM/DD/YYYY)

Incident reported to (name of Warden or Law Enforcement Agency):

How to Edit Form 4100-174 Online for Free

When an off-highway vehicle incident occurs, it's essential to report the details accurately for legal and safety purposes. The OHV Incident Operator Report (Form 4100-174) is designed for this, helping operators document crucial details about accidents involving vehicles like snowmobiles, ATVs, UTVs, or OHMs. Below is a step-by-step guide on how to fill out this form properly.

1. Provide Incident Details

Begin by entering the date, time, and day of the week of the incident. Specify the location, choosing from options such as private land, public land, public road, etc., and indicate the city, township, county, and state where the incident occurred.

 

Writing section 1 of wi dnr atv accident report

2. Describe the Incident

Note the number of vehicles involved in the crash. Check the appropriate boxes to indicate if the incident resulted in injuries requiring medical treatment, a fatality, or the disappearance of a person that suggests injury or death.

wi dnr atv accident report conclusion process outlined (step 2)

3. Write Vehicle and Operator Information

Fill in the type of vehicle involved (snowmobile, ATV, UTV, OHM) and provide detailed information about the operator, including name, address, phone number, date of birth, and experience level. Indicate whether safety training specific to OHVs was completed.

4. Detail Safety Equipment and Injuries

Mark whether safety equipment such as helmets or eye protection was used and note if seat belts were applicable and used. Describe the nature of any injuries sustained, categorizing them as minor or major, and provide a detailed description of the injuries.

Filling out segment 3 in wi dnr atv accident report

5. Additional Passenger and Vehicle Information

If other passengers were involved, enter their names, contact information, and any injuries they sustained. For the vehicle, provide details such as the make, model, year, vehicle ID number, engine size, and whether studs/chains were used. Note the estimated speed at the time of the incident and how many vehicles are designed to seat.

6. Information on Other Parties and Witnesses

If other parties were involved in the incident, provide their details and describe their involvement. List any witnesses, including their names, addresses, and contact information.

Part no. 4 for submitting wi dnr atv accident report

7. Describe the Environment and Circumstances

Specify the environmental conditions during the incident, such as weather, trail conditions, visibility, and road conditions. Select the type of incident from the provided options, such as collision with another vehicle, ejection from the vehicle, etc. Share your opinion on what contributed to the incident, like vehicle speed, inexperience, or equipment failure.

Writing segment 5 of wi dnr atv accident report

8. Provide a Narrative Description

In a separate section, describe what happened in a narrative format, detailing the events leading up to the incident. This part should provide a clear and comprehensive account of the incident's circumstances.

9. Review and Sign the Report

Double-check the report for accuracy, then print your name, sign, and date the form. Indicate to which law enforcement agency or warden the incident was reported.