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VEHICLE #

Check if Commercial

REPORTING AGENCY CASE NUMBER

HSMV CRASH REPORT NUMBER

1 Vehicle in Transport

VEHICLE LICENSE NUMBER

STATE

REGISTRATION EXPIRES

Check if Permanent

VIN

Registration

2 Parked Motor Vehicle

3 Working Vehicle

Hit and Run

YEAR

MAKE

MODEL

STYLE

COLOR

DAMAGE:

EST. AMOUNT

1 No

1 Disabling

4 Minor

2 Yes

2 Functional

88 Unknown

3 None

INSURANCE COMPANY

INSURANCE POLICY NUMBER

Towed due

VEHICLE REMOVED BY

1 Rotation

to Damage:

2 Owner Request

1 No 2 Yes

3 Driver

77 Other, Explain in Narrative

NAME OF VEHICLE OWNER

(Check if Business)

CURRENT ADDRESS

CITY & STATE

ZIP CODE

TRAILER #

LICENSE NUMBER

STATE

REGISTRATION EXPIRES

Check if Permanent

VIN

YEAR

MAKE

LENGTH

AXLES

Registration

TRAILER #

LICENSE NUMBER

STATE

REGISTRATION EXPIRES

Check if Permanent

VIN

YEAR

MAKE

LENGTH

AXLES

Registration

VEHICLE	N	S	E	W Off‐Road Unknown		ON STREET, ROAD, HIGHWAY		AT EST. SPEED POSTED SPEED		TOTAL LANES
TRAVELING
HAZ. MAT. RELEASED			HAZ. MAT PLACARD		HAZ. MAT. NUMBER	HAZ. MAT. CLASS	Area of Initial Impact		Most Damaged Area
1 No			1 No
2 Yes			2 Yes				18	Undercarriage	18
88 Unknown			88 Unknown				18	Undercarriage	18
88 Unknown			88 Unknown				19	Overturn	19
MOTOR CARRIER NAME					US DOT NUMBER		19	Overturn	19
MOTOR CARRIER NAME					US DOT NUMBER		20	Windshield	20
							20	Windshield	20
							21	Trailer	21
MOTOR CARRIER ADDRESS						CITY & STATE		ZIP CODE	PHONE NUMBER

Vehicle Body Type

Trafficway

Commercial Motor Vehicle Configuration

15 Low Speed Vehicle

1 Two‐Way, Not Divided

1 Vehicle 10,000 lbs or less Placarded

8 Truck Tractor/Triple

16 (Sport) Utility Vehicle

2 Two‐Way, Not Divided, with a

for Hazardous Materials

9 Truck more than 10,000 lbs (4,536

17 Cargo Van (10,000 lbs

Continuous Left Turn Lane

2 Single‐Unit Truck (2‐axle and GVWR

kg), Cannot Classify

(4,536 kg) or less)

3 Two‐Way, Divided, Unprotected

more than 10,000 lbs (4,536 kg))

10 Bus/Large Van (seats for 9‐15

18 Motor Coach

(painted >4 feet) Median

3 Single‐Unit Truck (3 or more axles)

occupants, including driver)

1 Passenger Car

19 Other Light Trucks (10,000 lbs

4 Two‐Way, Divided, Positive Median

4 Truck Pulling Trailer(s)

11 Bus (seats for more than 15

2 Passenger Van

(4,536 kg) or less)

Barrier

5 Truck Tractor (bobtail)

occupants, including driver)

3 Pickup

20 Medium/Heavy Trucks (more than

5 One‐Way Trafficway

6 Truck Tractor/Semi‐Trailer

77 Other, Explain in Narrative

7 Motor Home

10,000 lbs (4,536 kg))

88 Unknown

Trailer Type

7 Truck Tractor/Double

88 Unknown

8 Bus

21 Farm Labor Vehicle

1 Single Semi Trailer

11 Motorcycle

TRAILER 1 TRAILER 2

Cargo Body Type

12 Moped

77 Other, Explain in Narrative

2 Tandem Semi Trailer

8 Pole Trailer

13 Intermodal

13 All Terrain Vehicle (ATV)

88 Unknown

3 Tank Trailer

9 Towed Vehicle

3 Van/Enclosed Box

Container Chassis

4 Saddle Mount/Trailer

10 Auto Transport

4 Hopper

14 Vehicle Towing

Comm/Non-Commercial

5 Boat Trailer

77 Other, Explain in

5 Pole‐Trailer

Another Vehicle

1 Interstate Carrier

6 Utility Trailer

Narrative

6 Cargo Tank

15 Not Applicable

2 Intrastate Carrier

7 House Trailer

88 Unknown

1 No Cargo 7 Flatbed

(vehicle 10,000 lbs

3 Not in Commerce/Government

2 Bus

8 Dump

(4,536kg) or less not

9 Concrete Mixer

4 Not in Commerce/Other Truck

Comm

1 10,000 lbs (4,536 kg) or less

displaying HM placard)

Most Harmful Event

Non-Collision

2 10,001‐26,000 lbs (4,536‐11,793 kg)

10 Auto Transport

77 Other, Explain in

GVWR/GCWR

3 More than 26,000 lbs (11,793 kg)

11 Garbage/Refuse

Narrative

1 Overturn/Rollover

4 Not Applicable

12 Log

88 Unknown

2 Fire/Explosion

3 Immersion

Collision with Non-Fixed Object

Collision Fixed Object

29 Cable Barrier

Emergency

4 Jackknife

10 Pedestrian

19 Impact Attenuator/Crash Cushion

30 Concrete Traffic Barrier

5 Cargo/Equipment Loss or Shift

Vehicle Use

11 Pedalcycle

20 Bridge Overhead Structure

31 Other Traffic Barrier

6 Fell/Jumped From Motor Vehicle

12 Railway Vehicle (train, engine)

32 Tree (standing)

Sequence of Events

7 Thrown or Falling Object

13 Animal

21 Bridge Pier or Support

33 Utility Pole/Light Support

22 Bridge Rail

1st

2nd

8 Ran into Water/ Canal

14 Motor Vehicle in Transport

34 Traffic Sign Support

23 Culvert

9 Other Non‐Collision

15 Parked Motor Vehicle

35 Traffic Signal Support

24 Curb

[40‐46 Sequence of Events only]

16 Work Zone/Maintenance

25 Ditch

36 Other Post, Pole, or Support

1 No

40 Equipment Failure (blown tire,

Equipment

26 Embankment

37 Fence

2 Yes

brake failure, etc.)

17 Struck By Falling, Shifting Cargo or

27 Guardrail Face

38 Mailbox

88 Unknown

3rd

4th

41 Separation of Units

Anything Set in Motion by Motor

28 Guardrail End

39 Other Fixed Object (wall,

42 Ran Off Roadway, Right

Vehicle

building, tunnel, etc.)

43 Ran Off Roadway, Left

18 Other Non‐Fixed Object

44 Cross Median

Vehicle Maneuver Action

Traffic Control Device For

Vehicle Defects

45 Cross Centerline

1 Straight Ahead

13 Stopped in Traffic

This Vehicle

Roadway Grade

46 Downhill Runaway

3 Turning Left

14 Slowing

4 Backing

1 Level

Roadway Alignment

15 Negotiating a Curve

8 Flashing Signal

5 Turning Right

12 Suspension

2 Hillcrest

1 Straight

6 Changing Lanes

16 Leaving Traffic Lane

9 Railway Crossing

17 Entering Traffic Lane

1 None

13 Wheels

3 Uphill

8 Parked

Device

2 Curve Right

77 Other, Explain in

1 No Controls

2 Brakes

14 Windows/

4 Downhill

10 Making U‐Turn

10 Person (including

3 Curve Left

Narrative

3 Tires

Windshield

5 Sag (bottom)

11 Overtaking/

4 School Zone Sign/

Flagman, Officer,

88 Unknown

4 Lights (head,

15 Mirrors

Passing

Device

Guard, etc.)

signal, tail)

16 Truck Coupling/

5 Traffic Control

13 Warning Sign

9 Ambulance

Special Function

1 No Special Function

14 Intercity Bus

Signal

77 Other, Explain in

6 Steering

Trailer Hitch/

2 Farm Vehicle

10 Fire Truck

15 Charter/Tour Bus

6 Stop Sign

7 Wipers

Safety Chains

of Motor Vehicle

3 Police

11 Farm Labor Transport

16 Shuttle Bus

Narrative

9 Exhaust System

77 Other, Explain in

7 Yield Sign

88 Unknown

7 Taxi

12 School Bus

17 Farm Labor Bus

10 Body, Doors

Narrative

8 Military

13 Transit/Commuter Bus

88 Unknown

11 Power Train

88 Unknown

VIOLATIONS

PERSON #

NAME OF VIOLATOR

FL STATUTE NUMBER

CHARGE

CITATION NUMBER

PERSON #

NAME OF VIOLATOR

FL STATUTE NUMBER

CHARGE

CITATION NUMBER

PERSON #

NAME OF VIOLATOR

FL STATUTE NUMBER

CHARGE

CITATION NUMBER

HSMV 90010 S (V/P) (rev 06/13)

Page ___ of ___

PERSON #

REPORTING AGENCY CASE NUMBER

HSMV CRASH REPORT NUMBER

1 Driver

VEHICLE #

NAME

PHONE NUMBER

Check if

2 Non‐Motorist

Recommend

3 Passenger

Driver Re‐exam

CURRENT ADDRESS (Number and Street)

CITY & STATE

ZIP CODE

DATE OF BIRTH

SEX:

DRIVER LICENSE NUMBER

STATE

EXPIRES

INJURY SEVERITY (INJ)

1 Male

1 None

4 Incapacitating

2 Female

2 Possible

5 Fatal (within 30 days)

88 Unknown

3 Non‐incapacitating

6 Non‐Traffic Fatality

DRIVER

DL Type

Required Endorsements

Driver’s Actions at Time of Crash

3rd

Condition At

1 A 2 B 3 C

1 Yes

1st

1 No Contributing Action

26 Ran off Roadway

4 D/Chauffeur

2 No

2 Operated MV in Careless or

27 Disregarded other Traffic

Time of Crash

5 E/Operator

3 No Req. Endorsement

Negligent Manner

Sign

1 Apparently Normal

6 E/Oper – Rest

28 Disregarded Other Road

3 Failed to Yield Right‐of‐ Way

Asleep or Fatigued

7 None

Markings

4 Improper Backing

Ill (sick) or Fainted

Driver Distracted By

4 Other Inside the Vehicle

29 Over‐Correcting/Over‐

2nd

6 Improper Turn

Steering

4th

Seizure, Epilepsy, Blackout

1 Not Distracted

(explain in narrative)

Followed too Closely

30 Swerved or Avoided : Due

Physically Impaired

5 External Distraction

Ran Red Light

Emotional (depression,

2 Electronic Communication

to Wind, Slippery Surface, MV,

(outside the vehicle, explain

Drove too Fast for Conditions

angry, disturbed, etc.)

Devices (cell phone, etc.)

Object, Non‐Motorist in

3 Other Electronic Device

in narrative)

Ran Stop Sign

Roadway, etc.

Under the Influence of

(navigation device, DVD player)

6 Texting

15 Improper Passing

31 Operated MV in Erratic,

Medications/Drugs/Alcohol

7 Inattentive

17 Exceeded Posted Speed

Reckless or Aggressive Manner

77 Other, Explain in Narrative

Driver Vision Obstructions

88 Unknown

21 Wrong Side of Wrong Way

77 Other Contributing Action

88 Unknown

Failed to Keep in Proper Lane

1 Vision Not Obscured

5 Load on Vehicle

9 Smoke

2 Inclement Weather

6 Building/Fixed Object

10 Glare

DRIVER OR PASSENGER

3 Parked/Stopped Vehicle

7 Signs/Billboards

77 All Other, Explain

Helmet Use (HU)

Eye Protection (EP)

4 Trees/Crops/Bushes

8 Fog

in Narrative

Restraint Systems

1 DOT‐Compliant

1 Yes

DRIVER OR PASSENGER

(RS)

Motorcycle Helmet

2 No

Motor Vehicle Seating Position:

LOCATION: SEAT ROW OTHER

2 Other Helmet

3 Not Applicable

1 Not Applicable

Seat

Row

Other

(LOC)

3 No Helmet

2 None Used ‐ Motor Vehicle Occupant

Air Bag Deployed

5 Deployed‐Other

3 Shoulder and Lap Belt Used

1 Left

1 Front

1 Not Applicable

4 Shoulder Belt Only Used

2 Middle

2 Second

2 Sleeper Section of Truck Cab

(ABD)

(knee, air belt, etc.)

5 Lap Belt Only Used

3 Right

3 Third

3 Other Enclosed Cargo Area

Ejection (EJECT)

6 Deployed‐

6 Restraint Used

‐ Type Unknown

77 Other

4 Fourth

4 Unenclosed Cargo Area

1 Not Ejected

1 Not Applicable

Combination

7 Child Restraint System ‐ Forward Facing

2 Not Deployed

7 Deployed‐Curtain

8 Child Restraint System ‐ Rear Facing

(explain in

77 Other Row

5 Trailing Unit

2 Ejected, Totally

narrative)

88 Unknown

6 Riding on Motor Vehicle Exterior (non‐

3 Ejected, Partially

3 Deployed‐Front 88 Deployment

9 Booster Seat

88 Unknown

trailing unit)

4 Not Applicable

4 Deployed‐Side

Unknown

10 Child Restraint Type Unknown

88 Unknown

77 Other, Explain in Narrative

NON‐MOTORIST

Non-Motorist Description

Non-Motorist Location At Time of Crash

Action Prior to Crash

1 Pedestrian

1 Intersection ‐ Marked Crosswalk

8 Sidewalk

5 Walking/Cycling on Sidewalk

2 Other Pedestrian (wheelchair, person in a

2 Intersection ‐ Unmarked Crosswalk

9 Median/Crossing Island

6 In Roadway ‐‐ Other (working,

building, skater, pedestrian conveyance, etc.)

3 Intersection – Other

10 Driveway Access

playing, etc.)

3 Bicyclist

4 Midblock ‐ Marked Crosswalk

11 Shared‐Use Path or Trail

7 Adjacent to Roadway (e.g.,

4 Other Cyclist

5 Travel Lane ‐ Other Location

12 Non‐Trafficway Area

1 Crossing Roadway

shoulder, median)

5 Occupant of Motor Vehicle Not in Transport

6 Bicycle Lane

77 Other, Explain in Narrative

2 Waiting to Cross Roadway

8 Going to or from School (K‐12)

(parked, etc.)

7 Shoulder/Roadside

88 Unknown

3 Walking/Cycling Along

9 Working in Trafficway

6 Occupant of a Non‐Motor Vehicle

Roadway with Traffic (in or

(incident response)

Non-Motorist Actions/Circumstances

Transportation Device

adjacent to travel lane)

10 None

7 Unknown Type of Non‐Motorist

1 No Improper Action

4 Walking/Cycling Along

77 Other, Explain in Narrative

2 Dart/Dash

Roadway Against Traffic (in or

88 Unknown

1 None

Safety Equipment

1st

3 Failure to Yield Right‐of‐Way

adjacent to travel lane)

5 Lighting

4 Failure to Obey Traffic Signs,

2 Helmet

6 Not Applicable

Signals, or Officer

7 Entering/Exiting Parked/Standing

10 Improper Turn/Merge

3 Protective Pads Used

77 Other, Explain

5 In Roadway Improperly (standing,

Vehicle

11 Improper Passing

(elbows, knees, shins, etc.)

in Narrative

2nd

lying, working, playing)

8 Inattentive (talking, eating, etc)

12 Wrong‐Way Riding or Walking

4 Reflective Clothing (jacket,

88 Unknown

6 Disabled Vehicle Related (working

9 Not Visible (dark clothing, no

77 Other, Explain in Narrative

backpack, etc.)

on, pushing, leaving/approaching)

lighting, etc.)

88 Unknown

ALCOHOL/DRUG/EMS

SUSPECTED

ALCOHOL TESTED:

ALCOHOL TEST TYPE:

ALCOHOL

BAC

SUSPECTED

DRUG TESTED:

DRUG TEST

TYPE:

DRUG TEST RESULT:

ALCOHOL USE:

1 Test Not Given

1 Blood

TEST RESULT:

DRUG USE:

1 Test Not Given

1 Blood

1 Positive

1 No

2 Test Refused

2 Breath

1 Pending

1 No

2 Test Refused

3 Urine

2 Negative

2 Yes

3 Test Given

3 Urine

2 Completed

2 Yes

3 Test Given

77 Other,

3 Pending

88 Unknown

88 Unknown, if Tested

77 Other, Explain in

88 Unknown

88 Unknown, if Tested

Explain in Narrative

88 Unknown

Narrative

SOURCE OF TRANSPORT TO MEDICAL FACILITY

EMS AGENCY NAME OR ID

EMS RUN NUMBER

MEDICAL FACILITY TRANSPORTED TO

1 Not Transported

2 EMS

3 Law Enforcement

77 Other, Explain in Narrative

88 Unknown

ADDITIONAL PASSENGERS

PERSON #

VEHICLE #

NAME

DATE OF BIRTH

INJ

SEX

LOC: S

EJECT

ABD

CURRENT ADDRESS (Number and Street)

CITY & STATE

ZIP CODE

SOURCE OF TRANSPORT TO MEDICAL FACILITY

EMS AGENCY NAME OR ID

EMS RUN NUMBER

MEDICAL FACILITY TRANSPORTED TO

1 Not Transported

2 EMS

3 Law Enforcement

77 Other, Explain in Narrative

88 Unknown

PERSON #

VEHICLE #

NAME

DATE OF BIRTH

INJ

SEX

LOC: S

EJECT

ABD

CURRENT ADDRESS (Number and Street)

CITY & STATE

ZIP CODE

SOURCE OF TRANSPORT TO MEDICAL FACILITY

EMS AGENCY NAME OR ID

EMS RUN NUMBER

MEDICAL FACILITY TRANSPORTED TO

1 Not Transported

2 EMS

3 Law Enforcement

77 Other, Explain in Narrative

88 Unknown

HSMV 90010 S (V/P) (rev 06/13)

Page ___ of ___

Question	Answer
Form Name	Form Hsmv 90010 S
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	MV, HSMV, hsmv form 90010 s, INJ

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